THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


COMA 

A  HANDBOOK  FOR  THE  GENERAL  PRACTITIONER 


GLAUC  O  MA 

A   HANDBOOK   FOR 

THE  GENERAL  PRACTITIONER 


M.D.,   B  S.  I.OXD.,  SC.D.  EDIX.   F.K.C.S.  EXG.   ETC. 

LlECT.-COLOXEL   I  M.S.  (RETIRED) 

LATE  SUPERINTENDENT  OF  THE  GOVERNMENT  OPHTHALMIC  HOSPITAL,   MADRAS  ; 
LAI  E  PROFESSOR   Of  OPHTHALMOLOGY,    MEDICAL  COLLEGE.   MADRAS  ;     AXD  LATE  FELLOW 

OF  THE  UNIVERSITY  OF  MADRAS  ; 

HONORARY    FELLOW    OF    THE    AMERICAN    ACADEMY    OF    OPHTHALMOLOGY    AND 
OTO-LARYNGOLOGY. 


PAUL  B.  HOEBER 

67  &  69  EAST  59TH  STREET 

NEW  YORK 

1917 


Printed  in  England. 


So 
E.  C.  I.  E. 


00 
SYDNEY  STBPHENSON,  M.B.,  C.M.,  F.B.C.S.,  D.O. 

THIS 

BOOK  IS  DEDICATED 

IN  GRATEFUL  ACKNOWLEDGMENT  OF  THE^VERY  GREAT 
SERVICES  WHICH  HE  HAS  RENDERED  TO  OPHTHALMOLOGY 
IN  GENERAL,  AND  TO  THE  STUDY  OF  GLAUCOMA  IN  PAR- 
TICULAR, IN  THE  PAGES  OF  "THE  OPHTHALMOSCOPE," 
DURING  THE  FOURTEEN  YEARS  OF  THE  VERY  SUCCESSFUL 
APPEARANCE  OF  THAT  JOURNAL 


PREFACE 

DURING  the  last  ten  years  a  very  extraordinary  amount 
of  interest  has  been  taken  in  the  subject  of  glaucoma. 
At  no  time  in  the  history  of  ophthalmology  has  this  been 
equalled,  save  possibly  in  the  ten  years  which  followed 
the  declaration  of  von  Graefe's  great  discovery.  Between 
these  two  periods  of  interest  in  glaucoma,  dating  from 
the  start  of  each,  nearly  half  a  century  elapsed.  Though 
this  period  was  marked  by  no  spectacular  event  in  con- 
nection with  this  particular  subject,  it  was  none  the  less 
a  time  of  steady  progress  and  of  fruitful  speculation. 
Some  of  the  questions  which  puzzled  von  Graefe  can  be 
answered  by  a  student  to-day,  and  yet  we  are  far  from 
having  attained  finality.  There  are  still  many  matters 
on  which  authorities  are  at  variance.  There  are,  for- 
tunately, many  more  on  which  they  are  in  agreement. 

It  is  not  the  purpose  of  such  a  work  as  this  to  discuss 
the  former.  Space  and  common  sense  alike  forbid  such 
a  course.  The  aim  which  I  have  kept  before  me  has 
been  to  be  of  service  to  the  busy  medical  practitioner. 
The  importance  of  the  subject  appears  to  me  to  demand 
the  publication  of  a  monograph.  My  object  has  been  to 
writo  the  book  simply  and  concisely,  so  that  all  may 
understand  it,  shortly,  so  that  all  may  have  time  to 
read  it,  and  without  bias,  so  that  all  may  feel  its  appeal. 

Discussions  of  disputed  joints  have  been  avoided;  the 
views  expressed  are  those  which  are  current  amongst 
the  great  majority  of  ophthalmologists.  Names  of 

vii 


viii  PREFACE 

authorities    have    been    purposely    omitted.     A    certain 
amount  of  dogmatism  has  been  inevitable. 

The  material  for  a  much  more  exhaustive  treatise  on 
the  same  subject  lies  on  my  desk  to-day.  The  appeal 
of  that  work  will  be  to  the  scientific  ophthalmologist. 
In  it  subjects  will  be  discussed  at  length,  and  authorities 
freely  quoted.  Its  aim  will  be  widely  different  from  that 
of  this  little  book,  but  the  world-conflict  makes  the 
publication  of  such  a  work  an  impossibility  at  present. 
It  was  to  have  been  issued  first,  and  this  book  was  to 
have  followed  it.  Circumstances  have  been  too  strong 
for  the  carrying  out  of  this  intention;  and  now  that  the 
data  for  the  larger  work  are  all  ready  to  hand,  there  is 
nothing  to  hinder  the  publication  of  the  small  one,  which, 
after  all,  is  but  an  epitome  of  the  former.  The  book  is 
addressed  to  the  busy  general  practitioner  in  the  hope 
(1)  that  it  will  put  him  on  his  guard,  so  that  he  may  not 
overlook  cases  of  glaucoma  when  he  meets  them ;  (2)  that 
it  will  teach  him  to  make  sure  of  his  diagnosis  in  case 
of  doubt ;  and  (3)  that  it  will  serve  to  indicate  to  him  the 
latest  lines  along  which  the  treatment  of  the  disease  is 
conducted  to-day. 

54,  WELBECK  STBEET, 

CAVENDISH  SQUARE,  W., 
January,  1917. 


CONTENTS 


CHAPTER  PAQK 

I.  INTRODUCTORY-  -     1 

II.  THE  ANATOMY  OF  THE  PARTS  CONCERNED  IN  GLAUCOMA     3 

III.  THE  INTRA-OCULAR  PRESSURE,  AND  THE  TENSION  OF 

THE  EYE 

IV.  THE   PATHOLOGICAL   ANATOMY    OF   GLAUCOMA    - 
V.    THE   CAUSES   OF   GLAUCOMA 

VI.    THE   DIAGNOSIS   OF   GLAUCOMA- 
VII.    THE   SIGNS   AND    SYMPTOMS   OF   GLAUCOMA 
VIII.    THE   TREATMENT   OF   GLAUCOMA 
IX.    SECONDARY   GLAUCOMA - 
X.    CONGENITAL   AND   JUVENILE   GLAUCOMA 

INDEX     -  -  -  -  •  •  58 


LIST  OF  ILLUSTRATIONS 

no. 

1.  THE    FILTRATION    ANGLE    (ARTHUR   THOMSON)   -      Frontispiece 

MM 

2.  MERIDIONAL    SECTION    THROUGH    THE    ANTERIOR    POR- 

TION OF  THE  EYE  -                                         -    facing  3 

3.  THE  OPTIC  NERVE  ENTRANCE  -                     -  6 

4.  THE  ANGLE  OF  THE  CHAMBER,  OPEN  AND  CLOSED  facing  14 

5.  CUPPING  OF  THE  OPTIC  DISC    -                          -   facing  27 

6.  DEVICE    TO    EXPLAIN    THE    APPARENT    ALTERATION    IN 

THE  DIRECTION  OF  THE  VESSELS  AS  THEY  EMERGE 

FROM   A   GLAUCOMATOUS   CUP                                                 -  28 

7.  PHYSIOLOGICAL,    GLAUCOMATOUS,    AND    ATROPHIC   CUP- 

PING  OF   THE   OPTIC   DISC     -                                                    -  29 

8.  THE   VISUAL   FIELDS   IN    GLAUCOMA          -  32 

9.  THE    SCHIO'TZ   TONOMETER                                                                  -  33 

10.  LAGRANGE'S  OPERATION                                     -  facing  40 

11.  HOLTH'S  PUNCH  FORCEPS                                  •  41 
12 A.  SCLERO-CORNEAL  TREPHINING  -                                      -  42 

12B.  SECTION  OF  EYE  TO  SHOW  PARTS  CONCERNED  IN  TRE- 
PHINING       -              -              -              -              -  43 


GLAUCOMA 

CHAPTER  I 
INTRODUCTORY 

THE  term  "  glaucoma  "  is  not  the  title  of  any  one  single 
disease.  It  is  rather  a  convenient  clinical  label  for  a 
large  group  of  pathologic  conditions,  the  distinctive 
feature  common  to  all  of  which  is  a  rise  in  the  intra- 
ocular pressure. 

The  causes  of  these  conditions  are  many  and  varied, 
the  pathological  findings  are  most  diverse,  and  the 
difference  in  the  symptoms  presented  is  so  extraordinary, 
that  very  careful  study  is  required  to  detect  the  bond 
which  serves  to  unite  these  very  dissimilar  manifestations 
of  disease  in  a  common  category. 

When  we  speak  of  the  hardness  of  a  glaucomatous  eye, 
or  of  its  rise  in  tension,  we  are  referring  to  the  outward 
manifestations  of  an  increase  of  the  fluid  pressure  within 
the  globe.  To  this  increase  all  the  causes  of  glaucoma 
lead  up;  on  it  every  sign  and  symptom  of  the  condition 
depend. 

If  the  rise  in  pressure  can  be  traced  to  the  action  of 
some  antecedent  local  disease,  we  speak  of  the  glauco- 
matous condition  as  secondary ;  failing  this  we  term  it 
primary. 

The  presence  of  an  increase  in  intra-ocular  pressure 
necessarily  brings  about  some  measure  of  interference 
with  the  free  escape  of  blood  from  the  interior  of  the  eye 

1 


2  INTRODUCTORY 

to  the  surface.  So  long,  however,  as  such  interference 
does  not  give  rise  to  obvious  congestion  of  the  eye  or  of 
its  conjunctiva,  we  speak  of  the  condition  as  "  simple 
or  non-congestive  glaucoma."  When  evidence  of  inter- 
ference with  the  venous  return  makes  its  appearance, 
the  disease  is  said  to  be  congestive.  The  term  "in- 
flammatory," though  often  used  in  this  connection,  is 
erroneous  and  should  be  dropped. 

The  classification  of  all  cases  of  glaucoma  into  three 
groups — viz.,  the  acute,  the  sub  acute,  and  the  chronic — 
has  been  productive  of  much  confusion,  owing  to  the 
difference  in  the  way  in  which  these  terms  have  been 
used  by  writers  on  the  subject. 

Any  case  which  presents  the  signs  and  symptoms  of 
severe  congestion,  as  a  result  of  a  steep  rise  in  intra- 
ocular pressure,  may  reasonably  be  spoken  of  as  acute; 
similarly  with  eyes  presenting  the  signs  of  siibacute 
congestion.  To  define  a  chronic  case  is  more  difficult. 
All  that  the  term  really  implies  is  that  the  condition  has 
lasted  for  some  time;  but,  in  the  accepted  use  of  the 
term,  it  is  also  understood  that  the  case  is  not  in  an 
acute  or  subacute  stage.  Any  glaucomatous  eyeball, 
whether  of  the  simple  or  of  the  congestive  type,  may 
fall  into  this  category.  The  point  to  be  emphasized  is 
that  there  is  no  such  thing  as  acute,  subacute,  and  chronic 
glaucoma.  Any  glaucomatous  eye  may  be  in  an  acute, 
a  subacute,  or  a  chronic  stage,  and  may  readily  pass 
from  one  to  another  of  these  stages,  and  back  again  into 
that  from  which  it  sprang;  but  to  speak  of  acute,  sub- 
acute,  and  chronic  glaucoma,  as  if  we  were  dealing  with 
so  many  clinical  entities,  is  wrong  and  misleading. 


CHAPTER  II 

THE  ANATOMY  OF  THE  PARTS  CONCERNED 
IN  GLAUCOMA 

BEFORE  we  can  study  the  processes  of  disease  in  an 
organ,  or  the  methods  of  combating  them,  it  is  essential 
that  we  should  make  ourselves  acquainted  with  certain 
anatomical  details  of  the  structures  concerned. 

The  ciliary  body  and  the  parts  adjoining  it  are  "  the 
cockpit  "  of  glaucoma.  A  study  of  the  two  illustrations 
given  will  make  a  number  of  important  points  clear;  a 
few  of  the  more  essential  anatomical  features  demand 
some  notice. 

The  Conjunctiva. — It  will  be  noted  in  the  illustration 
(Fig.  2)  that  the  subconjunctival  tissue  is  continued  well 
in  advance  of  the  sclero-corneal  junction.  It  is  along 
this  layer  that  we  work  in  "  splitting  the  cornea  "  in  the 
operation  of  trephining,  and  the  looseness  of  the  tissue 
just  referred  to  explains  the  ease  with  which  that 
manoeuvre  is  conducted. 

Schlemm's  Canal  (Figs.  1  and  2)  lies  at  the  junction 
of  the  cornea  and  solera,  close  to  the  inner  surface  of  the 
corneo-scleral  envelope.  It  is  separated  from  the  aqueous 
chamber  only  by  the  loose  open  network  of  the  pectinate 
ligament  (Figs.  1  and  2).  Fluid  can  pass  readily  from 
the  chamber  to  the  canal  through  the  open  spaces  of 
this  mesh  work. 

The  Scleral  Spar  (Fig.  1)  lies  between  the  pectinate 
ligament  anteriorly  and  some  fibres  of  the  ciliary  muscle 

3 


4  GLAUCOMA 

posteriorly.  A  contraction  of  these  fibres  will  pull  back 
the  spur  and  tend  to  open  wide  the  canal  of  Schlemm. 
As  soon  as  muscular  contraction  ceases,  the  pectinate 
ligament  being  elastic,  will  draw  the  scleral  spur  back 
into  place,  and  so  close  the  canal  of  Schlemm  (Arthur 
Thomson).  It  is  suggested  that  the  pump  action  above 
described  is  repeatedly  in  action  during  life,  drawing 
the  fluid  from  the  anterior  chamber  into  the  canal  of 
Schlemm,  and  then  sweeping  it  on  again  from  the  canal 
into  the  neighbouring  veins. 

The  Angle  of  the  Chamber  (Fig.  2)  is  at  the  best  of  times 
a  narrow  space.  Inasmuch  as  the  outflow  of  the  aqueous 
fluid  takes  place  in  this  neighbourhood,  it  is  most  im- 
portant that  the  angle  should  remain  widely  open.  Its 
patency  may  be  infringed  in  several  ways. — 

1 .  Extreme  dilatation  of  the  iris,  by  crowding  the  mem- 
brane out  to  its  periphery,  tends  to  fill  up  the  angle,  and 
so  to  impede  the  passage  of  fluid  through  it. 

2.  The  ciliary  body  may  become  swollen  by  congestion 
with  blood.     If  it  does  so,  its  apices  move  forward.     A 
glance  at  the  illustration  (Fig.  2)  will  show  that,  if  this 
happens,  these  apices  will  press  upon  the  base  of  the  iris, 
and  push  the  latter  forward  against   the   cornea,  thus 
closing  the  angle.     A  second  point  may  be  learnt  from 
the  diagram.     If  the  apices  of  the  ciliary  body  move 
forward,  the  attachments    of  the  suspensory    ligament 
of  the  lens  do  the  same;  this,  obviously,  will  allow  the 
lens  to  advance,  and  so  to  press  on  the  base  of  the  iris. 

3.  As  life  advances,  the  lens  enlarges,  whilst  the  tunic 
of  the  eye  remains  stationary  in  size.     The  swollen  lens 
tends  to  press  the  iris  forward,  and  so  to  occlude  the 
angle,  just  as  in  the  previous  case. 

4.  When  the  iris  and  cornea  are  brought  into  close 
apposition  in  one   of  the   ways  above  described,  their 
adjacent  surfaces  are  apt  to  be  glued  together  by  the 


THE  ANATOMY  OF  THE  PARTS  5 

exudate  they  throw  out.  In  this  way  a  permanent 
obliteration  of  the  angle  may  be  brought  about. 

The  Iris. — On  the  anterior  surface  of  this  membrane 
are  found  pit-like  depressions,  the  crypts  of  the  iris 
(Fig.  2),  which  lead  to  the  depth  of  the  iris  stroma,  and 
which  place  its  tissue  spaces  in  free  communication  with 
the  cavity  of  the  aqueous  chamber.  In  this  stroma  the 
fluid  comes  into  intimate  contact  with  the  thin-walled 
iris  veins,  and  passes  into  the  latter  by  osmotic  action. 
The  crypts  are  of  importance  when  the  angle  of  the  cham- 
ber is  in  an  early  stage  of  closure,  for  the  fluid  from  the 
chamber  can  enter  through  them  and  find  its  way  along 
the  iris  stroma  to  the  neighbourhood  of  the  pectinate 
ligament,  across  which  it  then  passes  to  enter  Schlemm's 
canal. 

The  Ciliary  Body. — Whilst  few  authorities  now  accept 
the  suggestion  that  there  are  definite  tubular  secretory 
glands  in  this  body,  it  is  believed  that  its  lining  cells 
have  the  power  of  taking  up  fluid  transuded  into  their 
neighbourhood  from  the  capillary  vessels,  and  passing 
it  across  on  to  the  free  surface  by  a  definite  act  of  secretion. 

The  fluid  thus  poured  out  passes  by  two  streams,  one 
backward  into  the  vitreous,  and  the  other  inward  and 
forward  into  the  posterior  division  of  the  aqueous 
chamber;  thence  it  finds  its  way  through  the  pupil  into 
the  anterior  division  of  that  chamber,  and  flows  outward 
all  round  to  reach  the  angle. 

The  ciliary  body  presents  a  large  surface  of  attachment 
to  the  sclera.  This  is  of  interest  in  connection  with  the 
operation  of  cy do-dialysis,  the  purpose  of  which  is  to 
tear  the  former  structure  away  from  the  latter  over  the 
area  marked  out  by  a  limited  incision;  the  pectinate 
ligament  is  obviously  divided  during  this  step.  The 
object  aimed  at  is  to  open  up  a  communication  between 
the  anterior  chamber  in  front  and  the  suprachoroidal 


6 


GLAUCOMA 


space  behind,  by  means  of  the  detachment  of  the  ciliary 
body. 

The  vessels  and  nerves  which  supply  the  ciliary  body  and 
iris  pass  forward  between  the  choroid  and  the  sclera. 
In  this  course  they  are  exposed  to  the  full  force  of  the 
intra-ocular  pressure,  since  they  lie  against  the  hard 
unyielding  scleral  coat. 

There  is  a  free  communication  between  the  vascular 
system  in  the  interior  of  the  eye  and  that  on  its  surface 
through  the  perforating  vessels,  which  pierce  the  sclera 
close  behind  the  cornea.  Both  here  and  in  the  neigh- 
bourhood of  the  vasa  vorticosa,  the  evidence  of  con- 
gestion within  the  eye  is  to  be  looked  for  when  present. 


FIG.  3. — OPTIC  NERVE  ENTRANCE.     (Drawn  by  E.  E.  from  a  lantern 

projection  of  a  slide.) 
R,  Retina ;  8,  Sclera ;  O,  Optic  nerve  ;  V,  Central  vessel. 

The  whole  of  the  choroidal  and  retinal  circulation  lies 
between  the  fluid  contents  of  the  eye  and  the  unyielding 
sclera,  and  must  suffer  whenever  the  pressure  within  the 
eye  is  increased.  The  arterial  and  venous  circulations 
react  differently.  The  pressure  diminishes  the  amount 
of  blood  entering  the  eye  through  the  arteries,  and  also 
that  leaving  it  through  the  veins.  The  effect  is  to 
diminish  the  arterial  supply  and  to  establish  a  condition 


THE  ANATOMY  OF  THE  PARTS  7 

of  venous  congestion.  If  the  pressure  rises  slowly,  the 
circulation  can  adapt  itself  to  the  change  of  conditions, 
and  the  glaucoma  remains  simple.  If.  on  the  other  hand, 
the  increase  in  pressure  is  a  rapid  one,  no  such  adapta- 
tion is  possible,  and  an  attack  of  congestive  glaucoma  is 
the  result. 

The  optic  nerve  entrance,  being  the  weakest  part  of 
the  eye,  is  the  first  to  yield  under  a  rise  of  pressure, 
hence  the  cupping  of  the  optic  disc.  The  whole  nerve- 
head,  including  the  lamina  cribrosa,  is  pushed  backward 
Owing  to  the  fact  that  the  fibres  of  the  optic  nerve  lose 
their  medullary  sheath  as  they  pass  through  the  scleral 
coat,  the  bulk  of  the  nerve  diminishes  from  without 
inward;  consequently  a  section  through  this  part  shows 
the  nerve  presenting  roughly  the  appearance  of  a  trun- 
cated cone,  with  its  base  at  the  external  surface,  and  its 
truncated  end  at  the  fundus  (Fig.  3).  The  channel  in 
which  it  lies  has  the  same  form.  This  explains  the  shape 
of  an  advanced  glaucoma  cup,  the  overhanging  edges 
seen  in  the  cup,  and  the  apparent  interruption  in  the 
continuity  of  the  bloodvessels  which  emerge  from  it  (vide 
Fig.  5,  on  p.  27,  and  Fig.  7s,  on  p.  29). 


CHAPTER  III 

THE   INTRA-OCULAR   PRESSURE   AND   THE 
TENSION  OF  THE  EYE 

BEFORE  we  can  understand  the  aetiology  or  pathology  of 
glaucoma,  we  must  study  the  mechanism  whereby  the 
healthy  eye  is  kept  of  its  usual  shape,  and  at  a  normal 
tension. 

The  tension  of  an  eye  is  a  measure  of  the  state  of 
distension  of  its  tunic,  and  is  a  factor  which  can  be 
estimated  either  by  the  fingers  or  by  means  of  a  special 
instrument,  known  as  a  tonometer. 

The  intra-ocular  pressure,  on  the  other  hand,  is  the 
level  of  pressure  at  which  fluid  stands  within  the  eye; 
this  is  constantly  varying,  and  can  only  be  measured  by 
introducing  the  needle  of  a  manometer  into  the  globe, 
a  procedure  which  for  clinical  purposes  is  manifestly  out 
of  the  question. 

Practically  we  measure  the  tension,  and  then  seek  to 
arrive  at  the  intra-ocular  pressure ;  but  we  must  remember 
that  the  tension  of  a  globe  depends  on  other  factors 
beside  the  pressure,  the  most  important  of  these  being 
the  thickness  and  distensibility  of  the  ocular  tunic.  We 
must  therefore  be  very  careful  to  keep  the  two  terms 
distinct  in  our  minds. 

THE  PHYSICAL  CONDITIONS  EEGULATING  INTRA-OCULAR 

PRESSURE 

The  sclero-corneal  coat  of  the  eye  constitutes  a  more 
or  less  unyielding  tunic,  which  is,  however,  endowed 
with  a  degree  of  distensibility  and  of  elasticity,  properties 


THE  INTRA-OCULAR  PRESSURE  9 

which  are  best  marked  in  the  young  organ.  The  major 
part  of  the  contents  of  the  globe  consists  of  the  intra- 
ocular fluid.  This  fluid  is  constantly  being  changed; 
fresh  quantities  are  always  being  poured  out  by  the  ciliary 
body,  and  a  like  amount  is  as  constantly  being  drained 
away  at  the  angle  of  the  chamber,  and  from  the  surface 
of  the  iris.  In  this  way  a  measure  of  equilibrium  is  kept 
up.  Passing  through  this  fluid,  and  freely  bathed  by  it, 
are  the  bloodvessels  of  the  eye. 

It  is  probable  that  the  intra-ocular  fluid  is  poured  out 
as  the  result  of  a  combination  of  filtration  under  pressure 
and  active  cell  secretion.  As  a  result  of  the  former, 
fluid  is  expressed  from  the  capillaries  of  the  ciliary  body, 
and  is  accumulated  in  the  neighbourhood  of  the  epithelial 
cells  lining  the  surface  of  that  organ  (vide  Fig.  2);  these 
in  turn  pass  it  through  their  bodies  by  a  process  of  active 
secretion.  The  greater  the  difference  between  the  capil- 
lary blood-pressure  within  the  eye  and  the  intra-ocular 
pressure,  the  more  rapid  will  the  transudation  be.  More- 
over, a  freer  supply  of  blood  to  the  ciliary  body  will 
excite  its  cells  to  a  more  active  secretion. 

The  fluid  finds  its  way  back  again  into  the  circulation 
through  the  pectinate  ligament,  and  the  crypts  of  the 
iris  (vide  Fig.  1),  which  both  lead  into  the  veins  of  the 
eye.  This  return  is  effected  partly  by  osmosis,  and  partly 
by  a  pump  action,  of  which  the  motive  power  is  supplied 
by  the  ciliary  and  iris  muscles.  These  pull  open  the 
canal  of  Schlemm  each  time  they  contract,  whilst  the 
elastic  rebound  is  furnished  by  the  pectinate  ligament 
and  the  scleral  spur  (Arthur  Thomson). 

There  are  thus  two  simultaneous  and  closely  inter- 
dependent circulations  going  on  within  the  eye — viz., 
(1)  the  vascular,  and  (2)  that  of  the  intra-ocular  fluid. 
The  latter  is  fed  by,  and  returned  to,  the  vessels  of  the 
former  system. 


10  GLAUCOMA 

The  pressure  of  the  intra-ocular  fluid  (known  as  "  the 
intra-ocular  pressure  ")  depends  on  the  volume  of  the 
total  fluid  (blood  plus  intra-ocular  fluid)  in  the  eye  at 
any  given  time.  If  secretion  is  increased,  or  if  excretion 
is  impeded,  and  still  more  if  both  these  factors  are  active, 
the  volume  of  the  intra-ocular  contents  increases,  and 
can  only  then  be  accommodated  by  means  of  a  slight 
but  distinct  distension  of  the  external  coat  of  the  eye; 
to  this  distension  there  is  opposed  the  elasticity  of  the 
ocular  tunic.  The  pressure  of  the  contents  conse- 
quently rises,  until  the  limit  of  distensibility  and  of 
elasticity  is  reached,  when  the  eye  becomes  "  stony 
hard."  * 

Traced  back  to  its  first  cause,  the  intra-ocular  pressure 
depends  on  the  blood-pressure  within  the  eye.  As  in 
all  other  organs,  this  pressure  is  highest  in  the  arteries 
as  they  enter  the  globe,  and  lowest  at  the  points  of  exit 
of  the  veins  therefrom.  Speaking  generally,  the  intra- 
ocular blood-pressure  rises  and  falls  with  the  general 
or  systemic  blood-pressure,  but  wide  variations  from  this 
rule  may  occur. 

It  has  already  been  pointed  out  that  the  difference  in 
level  between  the  capillary  blood-pressure  in  the  eye 
and  the  intra-ocular  pressure  (i.e.,  the  pressure  of  the 
free  fluid  within  the  eye)  determines  the  freedom  of 
secretion  of  the  intra-ocular  fluid.  Therefore  a  rise  in 
the  capillary  pressure  will  cause  an  increase  in  the  volume 
of  intra-ocular  fluid,  and  vice  versa,  always  provided  that 
the  intra-ocular  pressure  remains  stationary.  Con- 
versely, a  rise  in  the  intra-ocular  pressure  will  lower  the 
rate  of  secretion,  by  tending  to  level  up  the  capillary  and 
intra-ocular  pressures,  and  again  vice  versa. 

It  is  essential  to  make  it  very  clear  that,  though  the 
systemic  blood-pressure  is  of  great  importance,  and  is, 
indeed,  the  foundation  element,  it  does  not  dominate 


THE  INTRA-OCULAR  PRESSURE  11 

the  whole  situation.     This  will  be  better  understood  if 
we  first  consider  certain  side-influences. — 

1 .  Any  factor  which  obstructs  the  outflow  of  fluid  from 
the  angle  of  the  chamber  tends  to  increase  the  volume  of 
the  intra-ocular  contents,  and  so  to  raise  the   pressure 
within  the  eye. 

2.  Any  factor  which  facilitates  the  outflow  from  the 
angle  of  the  chamber  must  have  the  opposite  effect.     In 
this  connection  it  is  important  to  remember  that  there 
is  evidence  that,   when  the  intra-ocular  pressure  rises 
under  physiological  conditions,  fresh  channels  of  excretion 
open,  or  else  the  existing  ones  enlarge,  and  so  the  removal 
of  the  excess  of  fluid  is  facilitated,  thereby  relieving  the 
pressure  within  the  eye.     It  is  highly  probable  that  the 
same  thing  occurs  under  pathological  conditions. 

3.  A  rise  in  the  intra-ocular  pressure  will  tend  to  close 
the  lumina  of  the  veins  at  the  points  where  their  pressure 
is  lowest — viz.,  just  where  they  are  passing  out  of  the 
eye;  for  the  pressure  here  is  only  a  little  above  that  of 
the  surrounding  intra-ocular  fluid.     We  know  this  is  so, 
because  if  we  press  lightly  with  a  finger  on  the  globe, 
whilst  using  an  ophthalmoscope,  we  can  see  the  lumina  of 
the  veins  close  up  at  their  proximal  ends.     We  infer  that 
under  ordinary  conditions  the  pressure  in  the  veins  is 
kept  at  such  a  level  that  the  current  of  blood  can  still  just 
escape  from  the  globe.     The  closure  of  the  venous  exits 
will  result  in  a  rise  of  the  venous  pressure,  until  the  ob- 
struction is  overcome .     Such  a  rise  will  work  back  through 
the  capillaries  towards  the  arteries.     An  obstruction  to 
venous  exit   will  therefore  in  the   first   instance   bring 
about  a  rise  in  capillary  blood-pressure.      Vice  versa,  a 
fall  in  venous  exit  pressure  will  cause  a  fall  in  capillary 
pressure.     Now,  a  rise  in  capillary  blood-pressure  favours 
an  increase  of  secretion,  provided  other  things  are  equal; 
whilst  a  fall  in  it  cuts  down  secretion. 


12  GLAUCOMA 

If  these  elements  of  the  situation  are  once  grasped. 
it  is  easy  to  understand  how  the  intra-ocular  pressure  is 
normally  maintained  at  a  steady  level,  for  each  factor 
that  would  tend  to  raise  or  lower  the  pressure  within  the 
eye  carries  with  it  compensating  influences.     How,  then, 
does  it  come  about  that  the  pressure  of  the  eye  ever 
rises   far   above   the    normal  ?     A   rise   in   intra-ocular 
pressure,  as  has  been  shown,  closes  the  venous  exits,  and 
so  raises  the  capillary  blood-pressure.     This  should  lead 
to  an  increased  escape  of  fluid  from  the  eye,  but  if,  owing, 
to  the  condition  of  the  excretory  channels,  it  cannot  do 
so,  the  volumetric  contents  of  the  eye  rise  instead  of 
fall,  as  they  normally  should.     Once  again  the  venous 
exits  tend  to  become  closed,  and  once  again,  in  response, 
the  venous  blood  is  dammed  back  until  the  vascular 
pressure  behind  it  suffices  to  force  the  obstruction.     Each 
time  this  occurs,  the  capillary  pressure  rises  correspond- 
ingly.    Relief  may  come  to  the  eye  either  (1)  by  the 
opening  up  of  fresh  channels  for  the  escape  of  the  intra- 
ocular fluid,  or  (2)  by  a  diminution  of  the  fluid  secretion, 
brought  about  by  the  fact  that  the  levels  of  the  vascular 
pressure  and  of  the  intra-ocular  pressure  have  become 
more   nearly  equalized.     If   no   such   succour   is   forth- 
coming, what  happens  to  the  eye  ?     Step  by  step  the 
venous  pressure  mounts  upwards,  and  with  it  the  capil- 
lary pressure,  until  the  whole  system  of  vessels  within 
the  eye  reaches  the  blood-pressure  level  of  the  arteries 
at  their  entrance  into  the  globe;  then  circulation  must 
cease  altogether. 

The  important  lesson  to  learn  is  that  the  great  factor 
which  dominates  every  other,  and  which  ultimately 
decides  the  level  at  which  the  intra-ocular  pressure  is 
to  stand,  is  that  of  the  volumetric  contents  of  the  eye. 
This  in  its  turn  is  determined  by  the  relative  rates  of 
secretion  and  of  excretion  of  the  intra-ocular  fluid. 


CHAPTER  IV 
THE  PATHOLOGICAL  ANATOMY  OF  GLAUCOMA 

IN  our  search  for  the  causes  of  a  disease,  we  turn  naturally 
to  a  study  of  its  pathological  anatomy.  In  the  case  of 
glaucoma  this  method  is  very  unsatisfactory,  as  all  our 
material  is  obtained  from  globes  far  advanced  in  the 
morbid  condition.  In  such,  the  changes  which  cause  the 
rise  in  tension  are  obscured  and  overlaid  by  those  which 
result  from  the  condition.  Consequently,  we  are  unable 
to  distinguish  between  cause  and  effect,  and  are  there- 
fore thrown  back  largely  on  clinical  observation.  The 
difficulty  is  heightened  by  the  fact  that  a  large  number 
oi  widely  different  conditions  are  grouped  under  the 
heading  of  glaucoma,  because  a  rise  in  the  pressure 
within  the  eye  is  the  leading  feature  in  all  alike. 

We  may  dismiss,  as  unworthy  of  serious  consideration, 
the  view  that  changes  in  the  vortex  veins  are  an  im- 
portant factor  in  causing  the  disease.  We  may  also  deal 
summarily  with  the  idea  that  glaucoma  is  primarily  a 
disease  of  the  vessels;  for  we  now  know  well  that  the 
familiar  vascular  changes  are  a  result,  and  not  a  cause, 
of  the  increase  in  intra-ocular  pressure.  Again,  we  can 
jettison  the  view  that  the  cupping  of  the  disc  is  due,  not 
to  an  increase  in  the  intra-ocular  pressure,  but  to  an 
active  atrophy  of  the  optic  nerve  itself.  It  remains  to 
deal  with  the  suggestion  that  the  cause  of  the  condition 
is  to  be  sought  in  a  change  in  the  tissues  of  the  eye, 
brought  about  by  the  deposit  in  them  of  waste  acid 

13 


14  GLAUCOMA 

products — with  the  result  that  they  take  up  moisture 
more  readily  than  natural,  and  swell  up  in  consequence. 
The  evidence  available  is  all  against  such  a  view. 

Fibrosis  of  the  Pectinate  Ligament. — It  has  been  shown 
that,  as  life  advances,  the  fibres  composing  the  pectinate 
ligament  become  thicker  and  thicker.  This  causes  them 
to  encroach  upon  the  spaces  of  the  open  network  of  the 
ligament.  It  has  been  suggested  (T.  Henderson)  that 
this  change  opposes  an  obstacle  to  the  free  passage  of 
aqueous  fluid  from  the  anterior  chamber  to  the  canal  of 
Schlemm,  since  the  current  finds  its  way  along  these 
open  clefts  or  spaces.  Again,  the  view  has  been  brought 
forward  (A.  Thomson)  that  the  changes  in  the  ligament 
may  interfere  with  the  pump  action,  whereby  fluid  is 
supposed  to  be  sucked  from  the  chamber  into  the  canal, 
since  the  rebound  after  each  stroke  of  the  muscular  (iris 
and  ciliary  muscles)  action  is  dependent  on  the  elasticity 
of  the  ligament.  That  both  these  factors  are  to  be  taken 
into  account  is  accepted,  but  it  must  be  remembered  that 
the  changes  in  the  ligament  are  said  to  be  invariably 
found  as  life  advances,  whilst  glaucoma  is  far  from  being 
so  widespread  as  this.  They  may  be  taken  to  be  con- 
tributory, but  no  more. 

Closure  of  the  filtration  angle  is  caused  by  the  iris 
base  being  pressed  against  the  periphery  of  the  cornea. 
At  first  the  closure  is  simply  mechanical,  the  two  sur- 
faces merely  lying  in  close  apposition.  Later  a  plastic 
exudation  is  thrown  out,  which  causes  the  two  membranes 
to  become  adherent  to  each  other.  Later  still  the  iris 
tissue  becomes  firmly  compressed,  and  eventually  under- 
goes atrophy.  The  final  stage  is  a  retraction  of  the 
ciliary  processes  which  drags  the  iris  back  with  them,  and 
may  even  tear  through  the  adhesions  between  it  and  the 
cornea. 

During  the  earlier  stages  of  the  process,  fluid  can  still 


PATHOLOGICAL  ANATOMY  15 

find  its  way  along  the  meshes  of  the  iris,  to  escape  by 
the  drainage  channels;  but  as  compression  asserts  itself 
such  a  flow  is  very  severely  interfered  with.  At  the 
same  time,  the  pressure  to  which  the  parts  are  subjected 
interferes  with  the  circulation  of  blood,  and  paves  the 
way  for  atrophy  to  follow. 

The  closure  of  the  filtration  angle  is  brought  about  by 
different  factors  in  different  cases.  In  congestive  glau- 
coma, the  ciliary  processes  are  enlarged  owing  to  engorge- 
ment by  blood,  and  consequently  push  the  iris  base 
forward  in  front  of  their  expansion.  At  the  same  time 
their  forward  movement  permits  the  lens  to  advance,  and 
this,  again,  in  its  turn  thrusts  the  iris  forward. 

In  .simple  glaucoma,  the  displacement  forward  of  the 
iris  is  a  result  of  the  enlargement  and  advance  of  the 
lens  which  take  place  as  life  progresses.  The  action  is 
much  slower  than  that  met  with  in  congestive  cases, 
and  the  tendency  to  the  formation  of  adhesions  is  much 
less.  It  only  remains  to  add  that  the  changes  in  the  lens 
just  discussed  are  also  operative  in  congestive  cases,  but 
their  role  is  then  a  subordinate  one  compared  with  that 
of  ciliary  congestion. 

The  changes  we  have  been  describing  naturally  lead 
to  a  shallowing  of  the  anterior  chamber.  The  latter  is 
well  known  to  be  a  leading  feature  of  glaucoma. 

The  Dimensions  of  Glaucomatous  Eyes. — The  eyes  of 
glaucomatous  persons  are,  as  a  rule,  smaller  than  those 
of  the  non-glaucomatous.  The  measurement  of  the 
transverse  diameter  of  the  cornea  furnishes  the  best 
indication  of  the  size  of  the  eye.  The  factor  of  real 
importance  is  the  relationship  between  the  size  of  the 
eye  and  that  of  its  contained  lens.  The  lens  grows  con- 
tinuously throughout  life,  whilst  the  cornea  of  the  foatus 
has  nearly  attained  its  full  dimensions  at  birth,  and  the 
sclera  ceases  to  grow  before  the  rest  of  the  body  does. 


ltj  GLAUCOMA 

Since  the  lens  grows  larger  and  larger  as  life  advances, 
whilst  the  globe  stands  still,  it  is  clear  that  the  older  the 
eye  becomes,  the  more  likely  is  it  that  the  lens  will 
become  too  large  for  safety;  and,  again,  the  smaller  the 
globe  is,  the  earlier  in  life  will  this  disproportion  occur 
(Priestley  Smith). 


CHAPTER  V 
THE  CAUSES  OF  GLAUCOMA 

HAVING    reviewed    the    pathological    anatomy    of    the 
subject,  we  now  pass  on  to  its  astiology. 

1.  Age  takes  precedence  over  all  known  causes  of  the 
disease.  In  the  earlier  decades  of  life  glaucoma  is  rare; 
its  frequency  increases  slowly  in  the  fourth  decade,  more 
rapidly  in  the  fifth  and  sixth,  remains  stationary  in  the 
seventh,  and  then  diminishes  again.  How  does  the 
advance  01  life  cause  glaucoma  ? 

(a)  By  bringing  about  alterations  in  the  anatomical  con- 
ditions of  the  parts.  Amongst  such  we  may  class  (i.)  en- 
largement of  the  lens,  (ii.)  advancement  of  the  lens  due 
to  slackening  of  its  zonule,  and  (iii.)  fibrosis  of  the  pecti- 
nate ligament. 

(6)  By  the  influence  of  degenerative  changes,  which  may 
lead  either  to  an  increase  in  the  volume  of  fluid  secreted 
by  the  eye,  or  to  a  change  in  the  constitution  of  that 
fluid  making  it  less  suitable  for  ready  nitration. 

(c)  By  rendering  the  eye  liable  to  auto-intoxication  and 
all  the  consequences  which  flow  therefrom. 

(d)  By  interference  with  that  free  and  even  working 
of  the  vascular  system  which  is  a  characteristic  of  healthy 
youth. 

2.  Sex. — Congestive  glaucoma  is  nearly  twice  as  com- 
monly met  with  in  the  female  as  in  the  male.  The 
unstable  condition  of  the  female  nervous  system  at  the 
time  of  the  climacteric  probably  accounts  for  the  disparity- 

17  2 


18  GLAUCOMA 

On  the  other  hand,  non-congestive  glaucoma  is  rather 
more  frequent  in  men  than  in  women. 

3.  Heredity. — The  influence  of  heredity  is  revealed  both 
in  the  race  and  in  the  family.     Jews,  Egyptians,  and 
certain  races  of  negroes,  are  believed  to  be  especially 
liable  to  the  disease. 

4.  Errors  in  Refraction. — The  idea  that  the  myope  is 
immune  from  glaucoma,  whilst  the  hyperope  is  especially 
liable  to  it,  is  a  myth.     Errors  in  refraction  probably 
play  a  very  small  part  in  the  aetiology  of  the  disease. 

5.  Mydriasis. — Anything  that  dilates  the  pupil  tends 
to  block  up  the  angle  of  the  chamber,  and  so,  by  causing 
an  obstruction  to  the  outflow  of  intra-ocular  fluid,  pre- 
disposes the  eye  to  glaucoma.     The  causes  of  dangerous 
mydriasis  are  (i.)  the  abuse  of  drugs;  (ii.)  the  exclusion^ 
of  light  from  the  eye;  (iii.)  the  influence  of  violentor 
exhausting  emotions;  and  (iv.)  the  effects  of  depressing 
disease.     On  this  subject  one  word  of  warning  is  de- 
manded.    There  is  no  drug  which  produces  mydriasis 
which  can  be  safely  instilled  into  an  eye  predisposed  to 
glaucoma,  unless  very  careful  safeguards  are  employed. 

6.  Nerve    Shock    and    Strain. — family    bereavement, 
haunting  fear,  business  anxiety,  long  fatiguing  anxious 
night-watches,  prolonged  mental  overwork,  sleeplessness, 
and    such-like    conditions,    are    often   the    factors    that 
determine  an  attack  of  glaucoma. 

7.  Febrile   Diseases. — These   may  act  in  one  of  two 
ways :  (a)  by  exhausting  the  vital  energies  of  the  patient, 
or  (6)  by  a  toxic  interference  with  the  vascular  arrange- 
ments of  the  eye,  or  with  the  integrity  and  efficiency  of 
the  secretory  and  excretory  mechanisms  of  the  globe. 

8.  Injuries. — Very  slight  injuries  of  the  eye  or  head 
sometimes  determine  an  attack  of  glaucoma.     Faute  de 
•mievx,  we  fall  back  on  the  explanation  of  an  interference 
with  the  vasomotor  mechanism  of  the  eye. 


CHAPTER  VI 
THE  DIAGNOSIS  OF  GLAUCOMA 

IN  the  great  majority  of  instances,  it  is  an  easy  matter 
to  make  a  correct  diagnosis  in  a  case  of  glaucoma.  The 
danger  of  a  failure  to  do  so  does  not  arise  from  any 
inherent  difficulty,  but  rather  from  the  surgeon's  forget  - 
fulness  of  the  possible  occurrence  of  the  disease  in  hi* 
practice.  Difficult  cases  are  undoubtedly  met  with,  and 
over  these  even  experts  may  differ ;  but  their  very  nature 
is  such  as  to  provoke  a  suspicion  of  glaucoma  in  the  mind 
of  any  practitioner.  Under  these  circumstances,  it  is 
not  difficult  for  him  to  put  the  responsibility  on  to  other 
shoulders.  The  essential  point  is  that  he  should  be  fore- 
warned, and  therefore  forearmed.  Every  patient  he 
meets  with  failing  vision  should  make  him  think  of  the 
possibility  of  simple  glaucoma.  Every  case  of  severe 
headache  he  is  called  in  to  treat  should  arouse  in  his 
mind  a  suspicion  of  congestive  glaucoma,  especially  if  it 
is  accompanied  by  vomiting. 

Early  diagnosis,  always  important,  has  become  much 
more  so  since  modern  methods  have  made  the  disease 
easier  and  safer  to  handle.  Congestive  glaucoma  is 
a  surgical  emergency,  whilst  the  simple  disease  is  a 
dangerous  pitfall  of  Medicine. 

There  is  no  such  thing  as  prodromal  glaucoma.  The 
disease  must  be  divided  into  three  stages:  (1)  the  early, 
the  time  of  election  for  treatment;  (2)  the  established, 
when  decisive  action  is  urgently  called  for;  and  (3)  the 
late,  often,  alas  !  too  late. 

19 


20  GLAUCOMA 

Glaucoma  is  divided  into  two  classes:  (a)  the  simple, 
or  non-congestive,  which  presents  no  evidence  of  marked 
vascular  disturbance;  and  (6)  the  congestive  (incorrectly 
termed  "  inflammatory  "),  in  which  an  obstruction  to 
the  efferent  veins  at  their  points  of  exit  from  the  eye 
causes  a  damming  up  of  blood  within  the  organ.  A 
case  may  be  simple  throughout,  or  congestive  throughout, 
or  the  one  form  may  pass  into  the  other  and  back  again 
into  that  from  which  it  first  sprang.  We  may  even  meet 
with  simple  glaucoma  in  one  eye,  and  with  the  con- 
gestive condition  in  its  fellow.  The  essential  feature, 
however,  in  all  cases  alike  is  an  obstruction  to  the  out- 
flow of  fluid  from  the  interior  of  the  eye  into  its  excretory 
channels.  Whether  a  congestive  element  enters  into  the 
case  is  largely  a  matter  of  chance,  in  which  the  anato- 
mical configuration  of  the  organ,  defective  development 
of  the  excretory  channels,  and  the  suddenness  of  the 
onset  of  the  changes  which  obstruct  excretion,  all  play 
a  part. 

The  Clinical  Course  of  an  Attack  o£  Simple  Primary 
Glaucoma. — The  onset  is  gradual,  the  signs  of  congestion 
are  absent,  there  is  no  pain  and  little  subjective  evidence 
of  any  kind;  but  the  visual  field  shrinks,  so  that  the 
patient  complains  that  he  feels  as  if  he  were  looking 
clown  a  tube  (tube-vision),  and  therefore  is  unable  to 
avoid  objects  with  which  he  meets.  Visual  acuity  often 
falls,  and  cupping  of  the  disc  is  soon  well  marked.  We 
may  speak  of  these  as  the  essential  triad  of  glaucoma 
signs,  and  put  them  shortly  as  (1)  contraction  of  the 
field,  (2)  cupping  of  the  disc,  and  (3)  failure  of  visual 
acuity.  So  gradually  may  the  symptoms  come  on  that 
the  patient  may  only  discover  their  existence  when  the 
first  eye  is  lost  entirely,  and  the  second  has  begun  to 
fail.  In  the  great  majority  of  cases  the  pupil  is  dilated 
and  sluggish.  Later  still  it  is  immobile,  and  surrounded 


THE  DIAGNOSIS  OF  GLAUCOMA  21 

by  only  a  narrow  margin  of  iris ;  rarely  it  may  be  of  normal 
size  until  quite  late  in  the  disease.  Sometimes  moderate 
or  even  good  central  vision  is  retained  for  a  long  time. 
An  increase  in  the  tension  of  the  globe  is  undoubted^ 
present  from  the  first  dawn  of  the  disease,  but  it  is  not 
always  recognized,  and  this  for  two  reasons — viz.,  (1)  that 
an  increase  in  the  intra-ocular  pressure  may  be  inter- 
mittent, and  therefore  not  always  in  evidence;  and 
(2)  that,  as  compared  with  congestive  glaucoma,  the  rise 
in  tension  is  quite  moderate  in  early  cases,  and  may 
escape  detection  by  digital  examination,  though  it  will 
be  revealed  by  the  use  of  the  tonometer. 

It  cannot  be  too  strongly  impressed  on  the  practitioner's 
mind  that  a  diagnosis  of  glaucoma  should  not  be  made  on 
any  one  sign  alone.  Every  possible  scrap  of  evidence, 
historic  or  clinical,  should  first  be  gathered;  a  broad 
view  should  be  taken,  and  judgment  should  then  be 
formed.  In  the  early  stage  a  decision  may  be  impossible ; 
careful  watching  of  the  patient  is  then  indicated.  Later, 
when  glaucoma  is  established,  the  most  ordinary  care 
suffices,  whilst  later  still  no  medical  man  could  mistake 
the  condition  for  anything  else. 

The  Clinical  Course  of  an  Attack  of  Primary  Con- 
gestive Glaucoma. — A  pronounced,  attack  of  congestive 
glaucoma  may  begin  without  warning  of  any  kind. 
More  often  it  is  heralded  by  the  appearance  of  the  so- 
called  "  prodromata,"  or  is  engrafted  upon  and  compli- 
cates an  attack  of  apparently  simple  glaucoma.  Such 
variations,  of  course,  are  very  numerous. 

In  most  cases,  the  patient  has  observed  that  from 
time  to  time  his  sight  has  become  misty  for  short  periods, 
generally  for  a  few  hours  at  a  time.  With  this  has  been 
associated  some  degree  of  pain  in  the  eye,  and  headache, 
together  with  the  appearance  of  rainbow  rings  around 
bright  lights  viewed  in  the  dark.  Flashes  of  light  are 


22  GLAUCOMA 

frequently  seen  before  the  eyes,  and  are  variously  de- 
scribed as  resembling  summer  lightning,  rolling  balls  of 
light,  sudden  flashing  luminous  points,  fireflies,  etc. 
During  the  attacks  the  pupil  is  dilated,  the  eye  con- 
gested, the  anterior  chamber  shallow,  and  the  cornea 
steamy.  Exhaustion,  sleeplessness,  fatigue,  or  worry, 
bring  on  the  crises,  whilst  rest,  food,  warmth,  and  sleep, 
cause  them  to  pass  away.  They  are  frequently  noticed 
either  in  the  early  morning,  or  in  the  late  afternoon  or 
evening.  Sooner  or  later  the  early  condition  passes  into 
the  phase  of  established  glaucoma.  The  transition  from 
one  to  the  other  may  be  gradual  and  imperceptible,  or, 
on  the  other  hand,  the  new  phase  may  be  ushered  in  by 
a  crisis,  whose  severity  is  such  that  the  patient,  quite 
erroneously,  dates  the  onset  of  his  disease/frtmi  ft: The 
leading  symptoms  are — (1)  severe  trigeminal  neuralgia, 
usually  referred  to  the  eye  and  forehead,  but  sometimes 
to  other  parts  as  well;  (2)  a  rapid  fall  in  vision;  and  (3)  a 
marked  contraction  of  the  visual  field.  The  eye  is  very 
congested,  as  also  are  the  lids.  Chemosis  may  be  present. 
The  cornea  is  steamy  and  insensitive ;  the  pupil  is  widely 
dilated  and  often  oval;  the  anterior  chamber  is  shallow; 
the  iris  appears  discoloured;  and  the  lens  has  a  peculiar 
green  look  (ry\avic6$  =  sea-green).  The  eye  is  very  tender 
and  painful,  and  is  felt  to  be  extremely  hard.  After 
a  varying  period  the  attack  passes  off,  leaving  the  eye 
permanently  damaged  and  in  a  condition  of  chronic 
glaucoma,  usually  of  a  congestive  type,  though  almost 
all  the  signs  of  interference  with  the  blood-stream  may 
pass  away.  The  downward  path  of  the  eye  is  punc- 
tuated by  the  more  or  less  frequent  occurrence  of  con- 
gestive exacerbations  of  the  disease.  It  will  thus  be 
seen  that  the  early  attacks  may  pass  gradually  into  the 
more  severe  ones,  or  the  latter  may  be  the  first  to  make 
their  appearance.  The  eye  is  grachially  drifting  towards 


THE  DIAGNOSIS  OF  GLAUCOMA  23 

an  established  condition  of  chronic  congestive  glaucoma. 
The  visual  acuity  is  impaired;  the  field  of  vision  is  con- 
tracted; the  tension  is  above  normal;  circumcorneal 
congestion,  with  distension  of  the  perforating  vessels,  is 
present;  the  cornea  readily  clouds  over,  and  is  losing  its 
sensitiveness;  the  anterior  chamber  is  very  shallow;  the 
pupil  is  wide  and  oval,  and  acts  sluggishly;  the  iris  is 
changing  in  colour,  and  atrophic  patches  are  appearing. 
If  the  media  are  clear,  we  can  see  in  the  fundus  (a)  the 
cupped  disc  surrounded  by  a  ring  of  atrophy,  (6)  the 
constricted  arteries,  (c)  the  congested  veins,  and  (d)  the 
vascular  pulsation,  all  of  which  are  characteristic  of 
glaucoma. 

Finally  we  come  to  the  "  late  stage  of  glaucoma,"  often 
spoken  of  as  that  of  "  absolute  glaucoma."  All  sight  is 
lost,  though  the  patient  may  protest  that  at  times  he  sees 
as  well  as  ever,  a  delusion  to  which  the  name  "  memory 
sight  "  may  be  applied.  The  green  reflex,  the  stone-like 
hardness  of  the  eye,  the  degenerative  changes  which 
mar  the  cornea,  and  the  porcelain-like  colour  of  the  sclera, 
with  the  dilated  vessel  standing  out  on  its  surface,  com- 
plete the  picture  already  drawn  of  the  earlier  stage. 
Even  now  there  are  possibilities  of  harm  to  be  added, 
since  the  patient  may  suffer  from  "  blind  painful  eye- 
ball," from  perforation  of  the  globe,  or  even  from  panoph- 
thalmitis. 

Let  us  pause  for  a  moment  to  lay  emphasis  on  certain 
points  in  connection  with  this  disease,  be  the  type  what 
it  may. — 

1.  It  is  bilateral,  and  therefore  complete  blindness  is 
threatened. 

2.  In  the  vast  majority  of  cases,  it  is  relentless  and 
progressive. 

3.  Its  keystone  is  a  rise  of  pressure  within  the  eye. 

4.  Its  fundamental  causes  are  protean. 


24  GLAUCOMA 

5.  One  and  all  of  them  act  by  upsetting  the  balance 
between  the  secretion  and  excretion  of  the  intra-ocular 
fluid. 

6.  The  entry  of  the  congestive  factor  into  the  drama 
is  an  accident,   though  one  of  the   very  gravest  pro- 
portions. 


CHAPTER  VII 
THE  SIGNS  AND  SYMPTOMS  OF  GLAUCOMA 

WE  shall  take  the  structures  of  the  eye  seriatim,  and 
consider  the  evidence  of  glaucoma  afforded  by  each. 

The  Conjunctiva  and  Solera.— The  only  change  seen  in 
simple  glaucoma  is  a  slight  enlargement  of  the  anterior 
ciliary  vessels,  especially  where  they  perforate  the  sclera. 

In  congestive  attacks,  the  condition  present  may  vary 
from  slight  circumcorneal  congestion  to  intense  reddening, 
and  even  to  chemosis.  In  the  intervals  between  attacks, 
a  permanent  enlargement  of  the  anterior  veins  is  always 
left. 

In  late  glaucoma,  the  sclera  has  a  bluish- white,  porce- 
lain-like appearance,  against  which  the  distended  anterior 
ciliary  veins  stand  out  in  marked  contrast. 

The  Cornea. — There  are  two  symptoms  occurring  from 
the  earliest  stage  of  congestive  attacks — viz.,  (1)  mistiness 
of  vision,  and  (2)  haloes  round  lights.  These  are  due  to 
two  causes :  (a)  an  overstretching  of  the  cornea  (the  result 
of  an  increased  intra-ocular  pressure),  which  interferes 
with  the  refraction  of  the  membrane;  and  (2)  an  actual 
oedema  of  the  corneal  layers,  the  result  of  an  obstructed 
circulation. 

The  mistiness  is  often  seen  in  the  mornings,  and  gives 
the  erroneous  impression  of  a  fog  or  of  smoke  in  the 
atmosphere.  The  haloes  round  lights  are  best  seen  at 
night,  and  are  clearest  around  yellow  flames.  At  least 
two  colours  are  &oen,  an  inner  blue  and  an  outer  red. 

25 


26  GLAUCOMA 

Anaesthesia  of  the  cornea  becomes  increasingly  marked 
as  glaucoma  progresses.  A  corneal  haze  makes  its  appear- 
ance in  some  cases,  and  in  late  stages  permanent  opacities 
of  the  cornea  are  found. 

The  Anterior  Chamber  is  always  shallow  during  con- 
gestive attacks;  later  it  becomes  permanently  so.  The 
depth  of  the  chamber  can  best  be  estimated  by  looking 
at  it  obliquely  from  the  opposite  side,  under  good  illumina- 
tion, with  a  loupe  or  an  ophthalmoscope.  The  contents 
of  the  chamber  are  often  turbid  in  congestive  cases. 

The  Iris. — Dilatation  of  the  pupil  is  found  in  most  cases 
of  glaucoma.  Exceptions  are  rare.  It  is  usually  well 
marked.  The  pupil  is  often  oval  in  form,  with  the  long 
axis  vertical.  In  congestive  cases  the  iris  may  be  dis- 
coloured. At  a  late  stage  atrophic  patches  appear  in  it, 
through  which  the  red  reflex  can  be  seen  on  ophthalmo- 
scopic  examination.  In  the  very  late  stages,  ectropion 
of  the  uveal  pigment  appears,  giving  the  edge  of  the 
pupil  a  velvety  black  line. 

The  Ciliary  Body. — Weakness  in  accommodative  power, 
shown  by  an  abnormal  increase  in  presbyopia,  is  the 
earliest  evidence  of  involvement  of  the  ciliary  body.  It 
is  an  important  point,  since  the  need  to  change  his  glasses 
soon  may  be  the  first  thing  to  drive  a  glaucoma  patient 
to  seek  medical  advice.  Later  a  congestion  of  the  circum- 
corneal  zone  shows  an  engorgement  of  the  ciliary  body 
with  blood. 

The  Lens. — Owing  to  the  advance  of  the  lens  system, 
as  the  anterior  chamber  shallows,  a  tendency  to  myopia, 
or  to  lessening  of  existing  hyperopia,  is  in  evidence. 
The  weakening  of  the  ciliary  muscle,  at  the  same  time, 
tends  to  bring  about  presbyopia,  as  above  indicated. 
These  factors  act  in  opposition,  but  the  latter  is  the 
stronger  and  therefore  the  prevalent  one. 

A  form  of  cataract  not  infrequently  complicates  glau- 


FIG.  5. — CUPPIKCJ  OF  THE  OPTIC  Disc  (GLAUCOMATOUS). 

Note  (1)  the  sharp  scleral  spur  on  the  right  side ;  (2)  the  overhanging  edges  ; 
and  (3)  the  retinal  vessels  hiding  under  the  latter.  x20.  (From  micro- 
photograph  kindly  supplied  by  Mr.  Chesterman. ) 


[To  face  p.  27. 


THE  SIGNS  AND  SYMPTOMS  27 

coma.  It  has  to  be  distinguished  from  cataract  occurring 
as  an  accidental  complication  of  the  condition.  In  some 
cases  cataract  is  the  first  morbid  condition  present,  and 
the  glaucoma  is  secondary  to  it.  The  history  and  ap- 
pearances of  the  eye  will  decide  which  condition  is 
present. 

The  green  reflex  in  the  pupil,  which  has  given  glaucoma 
its  name  (from  y\avK6s  =  sea-green),  is  produced  by  the 
dilated  pupil,  combined  with  some  want  of  transparency 
in  the  lens,  in  the  aqueous  humour,  and  in  the  cornea. 

The  Optic  Nerve  and  Retina. — The  changes  found  are — 

(1)  pallor  of  the  disc — this  is  partly  due  to  a  constriction 
of  the  blood-supply,  and  partly  to  advancing  atrophy  ; 

(2)  a  depression  of  the  floor  of  the  disc,  the  so-called 
cupping  of  the  disc  :  (3)  an  alteration  in  the  apparent 
direction  of  the  vessels  as  they  pass  from  the  disc  on  to 
the  surrounding  fundus;  (4)  the  presence  of  pulsation  in 
the  retinal  vessels ;  (5)  a  change  in  the  size  of  the  retinal 
arteries  and  veins. 

The  cupping  of  the  disc  is  the  best-known  and  most 
easily  detected  sign  of  the  disease.  It  is  due  to  the 
nerve  entrance  being  the  weakest  spot  in  the  globe,  and 
therefore  yielding  first  under  the  increased  pressure 
within  the  organ.  The  important  points  to  grasp  are, 
(a)  that  the  whole  of  the  disc  is  depressed  in  the  great 
majority  of  cases;  (6)  that,  as  each  vessel  passes  from  the 
disc  on  to  the  retina,  it  shows  a  kink  as  it  bends  over 
the  lip  of  the  cup ;  and  (c)  that  some  of  the  vessels  when 
traced  from  the  floor  of  the  disc  on  to  the  retina  seem  to 
change  their  direction  somewhat,  and  so  to  emerge 
parallel  with  what  might  have  been  expected  to  be  their 
course.  The  last-named  phenomenon  is  frequently  ill 
understood  by  students,  but  is  very  easily  made  clear 
by  the  aid  of  the  following  simple  device. — 

Take  a  half-sheet  of  note-paper,  7  inches  long  by  4| 


28 


GLAUCOMA 


wide  (the  exact  dimensions  are  unimportant),  and  join 
the  corners  by  drawing  two  diagonal  red  lines  (Kg.  6,  A). 
thus  making  a  multiplication  sign,  whose  four  arms  are 


A. — The  red  lines  are  to  represent  blood- 
vessels. The  dotted  lines  indicate 
where  the  paper  is  to  be  folded  the 
first  time. 


B.~ The  first  folding 
of  the  paper  shown 
complete ;  the  dotted 
lines  show  position 
of  the  second  fold. 


C  — The  second  fold- 
ing of  the  paper 
shown  completed. 


Si 


I). — The  double  flaps  raised  in 
concertina  fashion,  to  show 
the  overhanging  edge  of  the 
disc  and  the  apparent  altera- 
tion in  the  direction  of  the 
vessels,  as  they  emerge,  on 
the  plane  of  the  retina. 


FIG.  6. 


designed  to  represent  four  emerging  vessels.  Fold  each 
edge  of  the  paper  forward  towards  the  centre,  so  that 
the  two  edges  meet  each  other  over  the  centre  of  the 


29 

multiplication  sign  (Fig.  6,  B).  Take  each  edge  in  turn 
and  fold  it  backward  to  meet  the  first  folds  (Fig.  6,  C). 
Then  raise  the  two  double  flaps  so  made,  forward  in  a 
concertina-like  fashion,  and  look  down  on  the  device 
from  above  (Fig.  6,  D).  The  unfolded  part  of  the  paper, 
lying  flat  on  the  table,  diagrammatically  represents  the 
floor  of  the  disc ;  from  the  first  fold  to  the  second  on  each 

,s.sp. 


FIG.  7. 

A,  physiological  cup ;  B,  glaucomatous  cup ;  and  C,  cup  of  optic  atrophy 
(modified  from  Fucha).  O.N.,  Optic  nerve;  I.e.,  lamina  cribroso; 
S. ,  sclera ;  S.Sp.,  scleral  spur,  which  is  supposed  to  damage  the  retinal 
fibres,  as  they  bend  over  it ;  a,  a,  retinal  artery. 

side  represents  the  shelving  wall  of  the  disc;  from  the 
second  fold  to  the  free  edge  represents  the  fundus  level. 
The  apparent  break  in  the  continuity  of  the  straight  lines 
originally  made  is  very  striking,  and  aptly  illustrates  our 
point. 

In  late  cases,  the  retinal  vessels  are  sometimes  seen 
to  be  drawn  over  to  the  nasal  side,  in  what  looks  like  a 
leash. 


30  GLAUCOMA 

Pulsation  of  the  Retinal  Vessels. — If  the  veins  alone 
pulsate,  little  stress  need  be  laid  on  the  phenomenon: 
if,  however,  this  pulsation  is  strong,  and  if  a  light  pressure 
on  the  globe  with  a  forefinger  causes  the  arteries  to  pulsate 
as  well,  or  if  the  arteries  pulsate  even  when  the  globe  is 
untouched,  there  is  a  strong  suspicion  of  a  rise  in  intra- 
ocular pressure. 

A  Change  in  the  Size  of  the  Vessels. — The  arteries  tend 
to  become  more  constricted,  and  the  veins  larger  and 
fuller  than  natural. 

Caution. — A  glaucomatous  cup  must  be  distinguished 
from  a  physiological  cup,  from  an  atrophic  cup,  and  from 
a  coloboma  of  the  optic  nerve  (Fig.  7). 

The  physiological  cup  is  rarely  deep;  it  only  involves 
a  part  of  the  disc,  usually  the  outer  quadrant;  some  at 
least  of  the  vessels  pass  out  without  a  kink;  the  main 
part  of,  the  papilla  is  of  normal  colour. 

The  atrophic  cup  is  very  shallow,  the  disc  is  grey,  and 
the-  vessels  are  not  kinked. 

In  coloboma  the  apparent  disc  is  much  enlarged  and 
the  cup  is  of  great  depth.  The  history  of  the  case  may 
be  of  value. 

The  Retina  is  starved  of  arterial  blood,  and  the  outflow 
of  venous  blood  is  obstructed;  it  is  also  subject  to  direct 
pressure;  the  circulation  through  the  choroid  too  is  im- 
peded, and  consequently  the  outer  layer  of  the  retina 
has  its  nutrition  interfered  with.  The  result  is  a  limita- 
tion of  the  visual  field,  and  the  production  of  subjective 
sensations  of  light. 

The  Size  oi  the  Eye  should  always  be  noticed  in  glauco- 
matous cases.  It  can  best  be  judged  of  by  measuring 
the  diameter  of  the  cornea,  which  will  often  be  found 
to  be  below  normal.  The  average  horizontal  diameter 
of  the  cornea  in  healthy  subjects  is  11-6  mrn.  (Priestley 
Smith). 


THE  SIGNS  AND  SYMPTOMS  31 

Pain  varies  enormously  in  different  cases,  and  is  usually 
a  measure  of  the  congestion  present.  A  simple  glaucoma 
may  be  painless  throughout,  whilst  an  acute  congestive 
attack  is  marked  by  terrible  suffering.  There  is  severe 
neuralgia  not  only  in  the  eyes,  but  also  in  the  head,  teeth, 
ears,  and  neck.  The  agony  may  be  so  great  as  to  lead 
to  vomiting  and  pyrexia.  In  less  acute  cases,  the  pain 
and  headache  are  intermittent,  or  may  be  more  or  less 
constant.  Sleep,  food,  or  rest,  often  relieve  the  pain. 

Photopsise,  or  subjective  sensations  of  light,  are  due 
to  interference  with  the  retina.  They  may  occur  in  other 
affections  of  the  retina  and  choroid,  in  some  cases  of 
cerebral  disease,  in  megrim  and  other  nervous  affections, 
in  neurasthenic  patients,  under  conditions  of  cardiac 
syncope,  and  in  errors  of  refraction.  In  glaucoma  they 
are  worse  when  the  patient  first  lies  down,  and  are 
relieved  after  rest  as  the  night  advances,  whilst  in  cerebral 
cases  they  are  often  most  troublesome  later  in  the  night. 

Rainbows  round  lights  have  been  already  spoken  of. 
It  remains  to  add  that  similar  phenomena  may  be  ob- 
served in  conjunctivitis  owing  to  flakes  of  mucus  on  the 
cornea;  in  some  cases  of  early  cataract;  in  eyes  under- 
going various  forms  of  drug  treatment  (e.g.,  painting 
with  solution  of  silver  nitrate);  and  habitually  in  the 
eyes  of  certain  apparently  normal  people. 

A  Diminution  of  Visual  Acuity  may  be  due  to  lesions 
of  the  cornea,  to  opacities  in  the  aqueous  fluid,  in  the 
lens,  and  in  the  vitreous,  and  to  atrophy  of  the  optic 
nerve  and  retina . 

The  Visual  Field  is  early  affected,  and  affords  one  of 
the  most  delicate  tests  of  the  presence  and  advance  of 
glaucoma.  It  undergoes  a  characteristic  contraction, 
the  nasal  portion  usually  suffering  first  (Pig.  SA).  The 
colour  fields  are  but  little  affected;  central  vision  is 
usually  retained  till  quite  late.  The  most  delicate  test  of 


32 


GLAUCOMA 


THE  SIGNS  AND  SYMPTOMS 


all  is  that  devised  by  Bjerrum.  It  consists  of  examining 
the  field  with  a  very  small  object  (usually  1  mm.  in 
diameter)  at  the  relatively  great  distance  of  1  metre  or 
even  2  metres.  When  so  tested, 
it  is  found  that  the  visual  field 
is  much  smaller  than  the  nor- 
mal, and  that  the  scotoma  due 
to  the  blind  spot  is  much  en- 
larged, and  is  continuous  in  one 
direction  with  the  loss  of  the  peri- 
pheral field  (Fig.  SB).  Paracentral 
scotomata  are  also  observed,  and 
are  considered  to  be  of  consider- 
able importance  in  diagnosis. 

Tonometry. — The  old  method  of 
finger  tonometry  will  always  retain 
its  place  in  rough-and-ready  work, 
but  is  being  steadily  and  rapidly 
replaced  amongst  ophthalmologists 
by  the  use  of  the  Schiotz  tono- 
meter, or  of  some  modification  of 
that  instrument.  Mechanical  tono- 
metry, when  carefully  carried  out, 
is  of  the  greatest  value.  It  is,  how- 
ever, a  method  for  the  specialist 


FIG.  9. — THE  SCHIOXZ 
TONOMETER. 


rather  than  for  the  general  prac-    «  «>  sliding  ro  don  which  I, 

the  weight,  is  fixed ;  5,  a 


titioner. 


hollow  cylinder  in  which 
a  slides ;  c,  the  collar  on 
which  a  moves  by  wheel 
bearings ;  f,  foot-plate 
which  rests  on  the  eye. 
The  rod  a  actuates  the 
lever  above  it,  and  so 
records  on  the  scale  on 
the  arc. 


DIFFERENTIAL  DIAGNOSIS 

A  case  of  simple  or  non-con- 
gestive glaucoma  may  be  mistaken 
for  cataract,  for  an  error  in  re- 
fraction, or  for  an  affection  of  the  retina  and  choroid  or 
of  the  optic  nerve.  A  careful  examination  of  the  case 
will  usually  clear  the  matter  up  at  once ;  if  not,  it  must  be 

3 


34  GLAUCOMA 

kept  under  observation  for  a  while,  when  the  evolution  of 
the  cupping  of  the  disc  and  of  the  changes  in  the  field  will 
settle  the  question.  The  point  to  insist  strongly  upon  is 
that  in  all  such  cases  a  routine  examination  of  the  media, 
fundus,  fields,  and  tension,  is  urgently  demanded. 

Congestive  glaucoma,  on  the  other  hand,  is  often  mis- 
taken for  conjunctivitis,  for  iritis,  or  for  "  bilious  "  or 
other  headache. 

A  case  of  conjunctivitis  should  easily  be  distinguished 
from  one  of  congestive  glaucoma,  since  in  the  latter  we 
find — (1)  marked  circumcorneal  congestion;  (2)  steami- 
ness  of  the  cornea ;  (3)  dilatation  of  the  pupil ;  (4)  a  con- 
siderable rise  in  tension ;  (5)  severe  headache  and  neuralgia . 
None  of  these  signs  are  usually  present  in  eyes  suffering 
from  conjunctivitis. 

In  iritis  the  pupil  is  contracted,  and  the  loss  of  pattern 
and  the  change  in  colour  of  the  iris  are  prominent  features, 
whilst  the  tension  is  not  as  a  rule  raised. 

The  diagnosis  from  bilious  headache,  gastric  catarrh, 
and  other  conditions  associated  with  headache  and 
vomiting,  can  always  be  easily  made  by  any  surgeon 
who  will  trouble  to  examine  the  eyes.  So  long  as  it  is 
borne  in  mind  that  these  cases  may  possibly  be  glauco- 
matous,  there  is  not  the  least  danger  of  a  mistake  in 
diagnosis;  the  latter  can  only  arise  when  the  surgeon  is 
taken  off  his  guard. 


CHAPTER  VIII 
THE  TREATMENT  OF  GLAUCOMA 

THE  treatment  of  glaucoma  falls  naturally  under  two 
headings:  (1)  the  general  and  meiotic,  and  (2)  the  opera- 
tive. These  will  be  dealt  with  in  turn. 

The  General  and  Medicinal  Treatment  of  Glaucoma.— 
The  patient,  who  is  known  to  be  suffering  from  glaucoma, 
should  be  carefully  warned  to  regulate  his  Me  in  such  a 
way  as  to  avoid,  as  far  as  possible,  anything  which  may 
provoke  a  vascular  storm  in  the  eye.  A  list  should  be 
given  him  of  the  following  sources  of  danger:  constipa- 
tion, overfatigue  either  mental  or  bodily,  anxiety  and 
business  worry,  sleeplessness,  exposure  to  chill,  and 
any  form  of  violent  mental  excitement.  The  use  of 
any  form  of  mydriatic  drug  is  strongly  contra-indi- 
cated, unless  subsequent  meiosis  can  be  assured. 
Even  the  instillation  of  cocaine  may  be  dangerous.  If 
it  is  deemed  necessary  to  use  one  of  the  milder  mydriatics 
for  any  purpose,  the  patient  must  not  be  allowed  to  pass 
away  from  supervision  until  the  pupil  has  contracted 
again  under  the  influence  of  a  meiotic.  It  is  a  wise 
precaution  to  provide  the  patient  with  a  further  supply  of 
weak  eserine  or  pilocarpine  drops,  to  be  used  should  the 
pupil  tend  to  dilate  again  in  the  course  of  the  day. 

It  is  not  enough  to  give  general  warnings.  We  must 
never  forget  that  the  glaucomatous  eye  is  a  "  sick  eye 
in  a  sick  body."  Every  system  of  the  body  should  be 
overhauled  with  the  thoroughness  of  an  examination  for 
life  insurance,  special  attention  being  paid  to  the  vascular 

35 


36  GLAUCOMA 

and  urinary  organs.  Any  source  of  auto-genetic  poison- 
ing should  be  eliminated,  and  the  diet  and  habits  should 
be  carefully  regulated.  Alcohol  should  be  forbidden,  or 
at  least  strictly  limited.  It  is  to  be  remembered  that 
infectious  diseases,  and  amongst  these  we  may  especially 
mention  influenza,  carry  additional  dangers  to  the  victims 
of  glaucoma. 

Meiotics. — There  are  two  entirely  distinct  conditions 
under  which  meiotic  drugs  are  used;  these  are — (1)  in 
the  congestive  phases  of  glaucoma,  to  restore  the  eye  to 
its  normal  vascular  condition,  or  at  least  to  as  near  to 
that  as  may  be  possible;  and  (2)  in  the  absence  of  con- 
gestion, as  a  substitute  for  operative  treatment.  We  will 
take  these  points  in  order. 

In  congestive  attacks,  the  action  of  1  per  cent,  solutions 
of  eserine  or  of  pilocarpine  should  be  boldly  pushed,  the 
drops  being  instilled  every  few  hours  until  a  result  is 
obtained.  With  this  should  be  combined  free  leeching, 
active  purgation,  rest  in  bed,  milk  diet,  and  the  ad- 
ministration of  morphia  (unless  the  last-named  is  other- 
wise contra-indicated). 

If  it  is  decided  to  employ  meiotics  over  a  long  period 
in  chronic  congestive  cases,  pilocarpine  is  preferable  to 
eserine,  and  the  weakest  solution  that  will  keep  the  pupil 
contracted  should  be  used.  As  time  goes  by,  the  strength 
of  the  drops  may  require  to  be  augmented.  To  begin 
with,  half  a  grain  to  the  ounce  will  probably  suffice.  Care 
must  be  taken  to  counteract  the  tendency  of  these  drugs 
to  produce  chronic  catarrh  of  the  eye,  and  the  patient 
must  be  warned  never  to  let  his  stock  get  stale  or  run  out. 
In  this  connection  there  are  certain  important  warnings 
to  be  given. — 

1.  The  treatment  is  merely  palliative,  not  curative. 

2.  Meiotic  treatment  is  useless  in  simple  glaucoma. 
Its  only  role  is  in  cases  of  the  congestive  type. 


THE  TREATMENT  OF  GLAUCOMA     37 

3.  The  glaucoma  patient  should  be  kept  under  constant 
observation,  careful  periodic  examinations  being  made 
of  the  field  of  vision,  of  the  tension  of  the  eye,  of  the 
cupping  of  the  optic  disc,  and  of  the  visual  acuity.     The 
above  order  is  deliberate,  and  signifies  the  relative  im- 
portance to  be  attached  to  the  four  points.     Should  the 
condition  of  the  eye  be  deteriorating,  operative  treatment 
should  be  substituted  without  delay  for  the  medicinal 
regimen.     The  latter  has  sometimes  been  spoken  of  as 
"  expectant  treatment."     If  the  patient  is  losing  ground, 
it  can  be  expectant  only  of  disaster. 

4.  Every    authority    on   glaucoma    from    von    Graefe 
onwards  has  laid  stress  on  the  fact  that,  if  an  operation 
is  to  be  performed  for  the  relief  of  glaucoma,  the  earlier 
it  is  done,  the  better  is  the  chance  of  success.     Hesitation 
is   dangerous.     Once   we   see  that   other   measures  are 
failing,  we  must  recommend  and  carry  out  an  operation 
with  the  least  possible  delay. 

5.  The  exhibition  of  meiotics  can  only  have  a  rational 
basis  so  long  as  the  contractility  of  the  iris  is  unimpaired. 
Therefore  in  late  cases  it  is  useless. 

Massage. — The  great  value  of  massage  in  glaucoma 
does  not  appear  to  be  sufficiently  appreciated.  The 
tension  of  an  eye  can  be  quickly  and  sensibly  reduced 
by  digital  manipulation,  and  the  patient  can  be  taught 
to  perform  the  simple  movements  for  himself.  These 
are  two  in  number.  The  first  consists  in  placing  the  tips 
of  the  two  index  fingers  on  the  upper  lid  over  the  globe 
(the  surgeon  standing  behind  the  patient),  and  pressing 
with  each  finger  in  turn  in  the  direction  of  the  centre 
of  the  eye.  The  movements  should  be  slow  at  first,  and 
made  more  rapidly  later,  as  the  operator  acquires  skill 
and  the  patient  toleration;  the  subject  must  look  down- 
ward, and  gently  close  the  eyes.  The  period  of  massage 
should  be  short  at  first  (about  half  a  minute),  and  should 


38  GLAUCOMA 

be  extended  until  it  lasts  three  to  five  minutes,  thrice 
daily  or  more  often.  The  second  movement  is  a  gentle 
circular,  smoothing  action  performed  with  three  fingers 
of  one  hand,  through  the  gently  closed  lids.  It  serves 
the  same  purpose  as  the  wide  smoothing  movements  used 
after  massage  of  other  parts,  and  only  needs  to  be  done 
for  about  fifteen  or  twenty  seconds. 

Massage  of  the  eyes  should  be  just  as  much  a  routine 
measure  in  the  treatment  of  glaucoma  as  the  use  of 
meiotics  or  the  regulation  of  the  patient's  habits.  Not 
only  so,  but  it  is  also  a  measure  of  very  great  value  in 
augmenting  the  effect  obtained  by  operative  measures, 
when  that  proves  to  be  on  the  short  side. 

The  Operative  Treatment  of  Glaucoma. — We  begin  with 
a  short  description  of  the  various  operative  procedures 
before  the  profession,  leaving  the  reader  to  refer  for 
details  to  more  lengthened  treatises  on  the  subject. 

Iridectomy. — This  operation,  introduced  by  von  Graefe, 
held  sway  for  nearly  fifty  years,  until  its  supremacy  was 
challenged  by  the  procedures  which  aimed  deliberately 
at  the  formation  of  a  filtering  scar — i.e.,  a  scar  which 
allows  the  aqueous  fluid  to  escape  indefinitely  from  the 
interior  of  the  eye  to  the  potential  subconjunctival  space 
on  its  surface. 

The  removal  of  a  portion  of  iris  may  relieve  a  glauco- 
matous  patient  in  several  ways. — 

1.  If  performed  quite  early,  before  any  adhesions  have 
formed  between  the  iris  base  and  the  cornea,  it  establishes 
a  limited  space  over  which  the  normal  filtration  can  con- 
tinue unimpeded  either  by  dilatation  of  the  iris  or  by 
the  formation  of  adhesions  over  the  area  of  the  coloboma. 

2.  The  pressure  within  the  eye  is  temporarily  relieved. 
The  ocular  circulation  is  permitted  to  resume  its  normal 
character,  and  the  patient,  warned  by  the  severe  lesson 
hejias  received,  may  so  alter  his  life  habits  as  to  protect 


THE  TREATMENT  OF  GLAUCOMA     39 

himself  from  another  attack  for  a  long  time  to  come. 
The  predisposing  factors  of  glaucoma  are  ever  with 
him,  and  are  steadily,  if  slowly,  increasing  in  their  power 
for  harm,  but,  thanks  to  his  care,  the  exciting  causes 
are  as  far  as  possible  eliminated,  and  so  an  attack  is 
avoided. 

3.  A  filtering  cicatrix  may  be  accidentally  established 
as  a  result  of  the  operation,  though  this  is  not  what  was 
deliberately  aimed  at. 

Certain  plain  lessons  are  here  to  be  learnt. — 

(a)  If  iridectomy  is  to  be  useful,  it  must  be  done  at 
the  earliest  possible  stage  of  the  disease. 

(6)  The  incision  must  be  peripheral,  so  as  to  admit  of 
the  iris  being  removed  as  far  back  as  possible. 

(c)  The  incision  must  be  large,  so  that  the  portion  of 
iris  removed  shall  be  as  wide  as  possible;  this  insures  a 
wide  area  of  the  angle  for  free  drainage. 

(d)  If  we  desire  to  produce  a  filtering  scar,  we  should 
employ  an  operation  deliberately  designed  for  the  pur- 
pose, and  not  one  which  causes  it  only  by  accident. 

We  shall  now  pass  on  to  consider  the  various  pro- 
cedures which  aim  deliberately  at  the  production  of  a 
filtering  scar,  but  before  doing  so  we  must  make  it  quite 
clear  what  we  mean  by  this  term.  A  filtering  scar  is 
one  which  allows  the  intraocular  fluid  to  pass  through 
the  tunic  of  the  eye  into  the  subconjunctival  tissue,  and 
there  to  be  taken  up  by  the  lymph  and  blood  vessels. 
The  ocular  evidence  of  such  a  scar  is  a  boggy  or  oade- 
matous  condition  of  the  overlying  conjunctiva.  When  a 
probe  is  pressed  over  this  area,  marked  pitting  takes 
place.  It  has  been  pointed  out  that  a  similar  pitting 
may  be  demonstrated  in  some  normal,  and  in  not  a  few 
inflamed,  eyes.  It  is  necessary,  therefore,  to  emphasize 
the  point  that  the  pitting  over  a  true  filtering  scar  is 
more  marked,  and  usually  much  more  fluid,  than  that 


40  GLAUCOMA 

in  the  conditions  above  mentioned.  The  diagnosis  rests 
on  the  degree  and  fluidity  of  the  cedematous  condition. 

An  effort  has  been  made  to  distinguish  between  a 
"  filtering  scar "  and  a  "  fistulous  scar."  There  is, 
however,  no  anatomical  basis  for  the  view  that  it  is 
possible  to  establish  a  spongy  filtering  condition  of  such 
a  cicatrix,  and  it  is  safe  to  assume  that  all  cicatrices 
supposed  to  be  of  a  spongy  nature  are  in  reality  per- 
meated by  tiny  fistulae. 

Lagrange's  Operation. — Lagrange  was  the  first  to 
remove  a  portion  of  the  ocular  tunic  (sclerectomy)  in 
order  to  make  sure  of  establishing  a  filtering  scar.  The 
following  are  the  steps  of  the  operation. — 

1.  A  small  shelving  corneo-scleral   flap  is  cut  with  a 
Graefe  knife,  and  a   wide   conjunctiva   apron  is  added 
thereto  (Fig.  10A). 

2.  The  conjunctival  flap  is  turned  down,  and  the  cor- 
neal  lip  of  the  wound  is  removed  with  scissors  (Fig.  10B). 

3.  Iridectomy  is  performed,  if  required  (Fig.  lOc). 

4.  The  flap  is  stroked  into  position  and  the  wound 
closed. 

The  result  of  the  operation  may  be  seen  in  Fig.  10D. 

Herbert's  Operations  must  be  spoken  of  in  the  plural, 
as  the  exact  procedure  has  varied  from  time  to  time. 
The  underlying  idea  of  all  of  them  has  been  to  obtain 
a  filtering  scar  by  a  modification  of  the  operation  of 
sclerotomy.  We  shall  take  the  procedures  seriatim. 

1.  Has  first  attempt  (1906)  was  to  make  the  lips  of  a 
small  sclero-corneal  incision  as  jagged  as  possible,  in 
order  to  prevent  primary  union,  and  so  to  obtain  a 
permanently  weak  scar. 

2.  In  1907  he  introduced  the  wedge  isolation  operation, 
the  object  of  which  was  to  isolate  a  wedge  of  solera  close 
to  the  limbus,  and  to  leave  it  in  situ,  in  the  hope  that, 
being  cut  off  from  its  blood-supply,  it  would  shrink,  and 


.4.— Section  of  the  Sclera  and  Conjunctiva. 


B. — Resection  of  the  Sclerotic. 
FIG.  10.— ILLUSTRATING  LAGRANGE'S  OPERATION  (A,  B). 

[To  face  p.  40. 


C. — The  Making  of  the  Iridectomy. 


D. — The  Result  of  the  Operation. 
FIG.  10.— ILLUSTRATING  LAGRANGE'S  OPERATION  (C,  D). 

[To  face  p.  40. 


THE  TREATMENT  OF  GLAUCOMA     41 

so  allow  of  filtration  from  the  interior  of  the  eye  into 
the  subconjunctival  space  around  its  margins. 

3.  Later  he  introduced  his  small  flap  operation,  which 
consisted  in  the  making   of  a  small  keratome  incision 
from  behind  the  limbus   into  the  chamber,   and  then 
carrying  two  or  four  cuts  forward  at  right  angles  to  this, 
in  order  to  form  a  trap-door  flap  of  solera.     The  cuts 
were  made  with  special  scissors. 

4.  Latterly  he  appears  to  have  gone  back  to  a  pro- 
cedure that  he  favoured  in  his  earliest  efforts — namely, 
the  attempt  to  establish  a  fistula  by  tucking  conjunctival 
tissue  into  a  scleral  wound  close  behind  the  limbus.     The 
tuck  is  kept  in  place  by  a  metal  plug,  sutured  in  position 
and  kept  there  for  some  days  following  the  operation. 


FIG.  11. — HOLTH'S  PUNCH  FORCEPS. 

The  drawback  to  all  these  procedures  is  that,  like  their 
prototype  sclerotomy,  they  are  apt  to  fail  owing  to 
healing  up  of  the  wounds  made.  On  the  other  hand, 
it  is  only  fair  to  add  that  Herbert's  contention  is  that 
the  modern  operations,  which  remove  a  definite  piece  of 
sclera,  are  apt  to  do  too  much. 

Holth's  Operation. — A  sclero-corneal  flap  is  cut  with 
a  keratome,  a  conjunctival  apron  being  fashioned  by 
entering  the  knife  into  the  conjunctiva  some  distance 
above  the  point  of  scleral  puncture.  Iridectomy  follows, 
and  then  the  anterior  lip  of  the  wound  has  a  tongue  cut 
out  of  it  by  means  of  a  specially  designed  punch.  The 
flap  is  replaced  in  position. 

Fergus's  Operation. — A  conjunctival  flap  is  dissected 


42 


GLAUCOMA 


up  to  the  cornea,  but  not  into  it;  a  disc  of  solera  is  cut 
out  with  a  3  mm.  trephine,  close  up  to  the  limbus;  in 
a  certain  number  of  cases  a  cyclo-dialysis  is  added;  the 
ciliary  body  is  laid  bare  in  the  wound.  Some  stress  is 
laid  on  the  opening  up  of  a  communication  between  the 
anterior  chamber  and  the  suprachoroidal  space. 

Sclero-Corneal  Trephining  (the  author's  operation)  has 
sometimes  been  confused  with  the  last-named  operation, 
with  which  it  has  little  in  common,  beyond  the  fact  that 


wwwiA/yi/ 


FlG.    12A. — SCLERO-CORXEAI,  TREPHINING. 

sp,  speculum ;  ii,  incision  in  conjunctiva ;  c,  cornea ;  t,  trephine-hole ;  p,  pupil ; 
aa,  uncut  conjunctiva,  which  serves  to  allow  filtering  fluid  from  the  neigh- 
bourhood of  the  trephine-hole  to  pass  into  the  rest  of  the  subconjunctival 
space. 

a  trephine  is  used  in  both  of  them.  The  object  of  the 
procedure  is  to  tap  the  anterior  chamber,  to  drain  it 
permanently  into  the  subconjunctival  space,  and,  in 
doing  so,  to  avoid  if  possible  any  interference  with,  or 
impaction  of,  the  uveal  tract.  An  incision  concentric 
with  the  cornea  maps  out  a  large  conjunctival  flap,  which 
is  dissected  down  to  the  limbus,  the  whole  thickness  of 
the  tissue  being  taken  up.  The  dissection  is  carried  on 
into  the  substance  of  the  cornea  for  another  millimetre, 


THE  TREATMENT  OF  GLAUCOMA     43 

the  cornea  being  actually  "  split  "  over  this  area.  This 
flap  being  held  down  out  of  the  way,  a  2  mm.  trephine 
blade  is  next  applied  to  the  corneo-scleral  margin,  and 
a  disc  is  cut  out  in  such  a  manner  that  it  remains  hinged 
on  the  scleral  side.  At  the  same  time  the  iris  protrudes 


FIG.  12B. — DIAGRAM  TO  SHOW  IN  SECTION  THE  RELATION  OF 
THE  PARTS  IN  A  TREPHINED  EYE. 

a,  normal  position  of  conjunctiva;  b,  conjunctiva  reflected  on  to  the  cornea, 
after  " splitting  "  of  that  membrane;  ab,  area  of  the  crescent  formed  by 
"splitting"  the  cornea;  c,  the  piece  of  sclero-cornea  removed  by  the 
trephine  (it  is  shown  shaded);  d,  iris ;  e,  ciliary  body ;  /,  lens ;  y,  cornea ; 

k,  sclera. 

through  the  opening.  The  disc  and  iris  are  seized  in 
one  grip  of  a  pair  of  iris  forceps,  and  cut  off  with  a  single 
snip  of  the  scissors.  The  iris  is  replaced,  and  the  con- 
junctiva is  smoothed  into  position  and  sutured  there.  The 
advantages  claimed  for  this  procedure  are  as  follows. — 
Its  technique  is  not  difficult;  the  sclerectomy  on  which 


44  GLAUCOMA 

drainage  depends  is  the  smallest  possible,  and  is  made 
on  an  intact  globe;  consequently  the  dangers  of  vitreous 
prolapse  and  of  intra-ocular  haemorrhage  are  reduced  to 
a  minimum;  finally,  the  operation  can  be  repeated,  if 
need  be.  The  accompanying  illustrations  (Figs.  12A, 
12B)  serve  to  make  the  steps  of  the  operation  plain. 
Full  details  of  the  method  are  to  be  found  in  the  author's 
book  on  the  subject.* 

Thread  Drainage. — A  number  of  operations  have  been 
put  forward  in  which  a  thread  is  introduced  into  the 
anterior  chamber,  and  its  ends  are  buried  in  the  sub- 
conjunctival  tissue.  It  has  been  supposed  that  they 
would  favour  the  spread  of  drainage  under  the  flap. 
If  any  of  the  modern  operations  are  carefully  performed, 
there  will  be  little  difficulty  in  the  diffusion  of  the  drainage 
fluid.  On  the  other  hand,  the  introduction  of  a  piece 
of  thread,  in  free  communication  with  the  interior  of  the 
eye,  appears  to  be  a  needlessly  dangerous  procedure. 
Recognizing  this  risk,  Prince  has  substituted  a  gold 
drain  for  the  thread.  If  a  drain  is  to  be  used  at  alL 
this  is  certainly  a  preferable  expedient. 

Cyclo-dialysis,  or  the  separation  of  the  ciliary  body 
from  its  attachment  to  the  solera,  was  designed  to  open 
up  a  communication  between  the  anterior  chamber  and 
the  suprachoroidal  space.  It  is  now  very  seldom  re- 
sorted to. 

Two  subjects  remain  to  be  discussed : — (1)  the  operation 
to  be  selected  in  any  individual  case;  and  (2)  the  argu- 
ments that  can  be  used  against  the  undertaking  of  any 
operative  procedure. 

1.  The  Selection  o£  an  Operation. — There  is  at  the 
present  time  the  greatest  diversity  of  opinion  amongst 

*  "  Sclero-Corneal  Trephining  in  the  Operative  Treatment  of 
Glaucoma"  (second  edition,  1914),  by  Lieut. -Colonel  R.  H. 
Elliot.  London:  George  Pulman  and  Sons,  Ltd. 


THE  TREATMENT  OF  GLAUCOMA     45 

experts  on  this  subject.  There  are  those  who  would 
perform  iridectomy  in  all  cases;  there  are  others  who 
would  always  resort  to  one  or  other  of  the  forms  of 
filtering  operations;  there  are  still  others  who  would 
select  the  operation  according  to  the  case.  Much  depends 
upon  the  idiosyncrasy  of  the  surgeon  and  on  his  past 
experience.  There  is  no  rule  to  be  laid  down.  The 
practitioner  will  be  well  advised  to  leave  such  technical 
matters  to  the  judgment  of  the  surgeon  he  calls  in.  At 
the  same  time  it  should  be  said  that  there  are  a 
very  large  number  of  surgeons  who  hold  to  the  broad 
general  rule  to  perform  iridectomy  in  acute  and  subacute 
cases,  and  a  filtration  operation  in  chronic  ones.  The 
author's  personal  view  is  that  sclero-corneal  trephining 
is  the  safest,  the  easiest,  and  the  simplest  operation  in 
any  and  every  case  of  glaucoma,  with  two  exceptions. 
These  are  (1)  glaucoma  secondary  to  the  swelling  of  a 
maturing  cataract,  and  (2)  that  which  follows  any  con- 
dition which  places  the  aqueous  and  vitreous  chambers 
in  free  continuity  with  each  other.  He  can  claim  that 
this  view  is  founded  on  a  large  practical  experience,  and 
that  it  is  supported  by  that  of  a  number  of  very  able 
surgeons;  at  the  same  time,  he  would  freely  admit  that 
many  dissent  from  it. 

2.  The  Arguments  against  Operation. — These  are  four 
in  number : 

(i.)  There  are  a  certain  number  of  cases  of  glaucoma 
on  record  in  which  the  status  quo  has  been  maintained 
for  years  by '  medicinal  treatment  alone.  These  rare 
instances  have  encouraged  many  surgeons  to  delay  opera- 
tion, and  have  caused  a  loss  of  sight  out  of  all  proportion 
to  the  meagre  gains  which  can  be  laid  to  the  credit  of 
the  "  expectant  treatment." 

(ii.)  Any  operation  for  glaucoma,  at  a  late  or  com- 
paratively late  stage  of  the  disease,  may  be  followed  by 


46  GLAUCOMA 

a  considerable  deterioration  in  visual  acuity,  associated 
with  a  marked  loss  of  field.  The  author  believes  that 
such  cases  never  occur  if  operation  is  undertaken  early, 
and  that  even  in  the  late  stage  they  are  rare  in  modern 
filtration  operations,  as  compared  with  iridectomy. 
Against  this  must  be  set  the  hopeless  prognosis  of  the 
very  great  majority  of  cases  of  glaucoma  when  left  to 
themselves. 

(iii.)  Much  stress  has  been  laid  on  the  bad  late  results 
that  may  follow  an  operation  for  glaucoma,  and  especially 
on  the  danger  of  "late  infection."  By  that  term  is 
understood  an  infection  of  the  eye  through  the  operation 
wound,  long  after  the  latter  has  healed,  and  quite  inde- 
pendent of  the  introduction  of  sepsis  at  the  time  of 
operation.  This  accident  has  followed  all  forms  of  opera- 
tive procedure,  including  iridectomy  and  sclerotomy, 
but  it  is  probably  more  frequent  in  those  cases  in  which 
a  filtering  scar  has  been  deliberately  produced.  Much 
may  be  done  to  lessen  this  danger  by  the  use  of  a  proper 
technique  at  the  time  of  operation.  At  the  same  time 
it  would  be  idle  to  belittle  the  danger.  We  must  face 
the  question  and  deal  with  it  in  the  large.  The  per- 
centage of  risk  does  not  appear  to  be  very  high,  especially 
if  suitable  care  be  taken.  On  the  other  hand,  the  con- 
dition for  which  we  are  undertaking  operation  is  an 
extremely  serious  one,  and  justifies  us,  up  to  a  certain 
point  at  least,  in  taking  some  chances. 

(iv.)  There  is  a  hesitation  amongst  surgeons  in  under- 
taking any  new  form  of  procedure.  This  attitude  is  not 
merely  comprehensible,  but  within  limits  it  is  justifiable. 
Tune  and  a  favourable  experience  alone  will  serve  to 
break  it  down. 


CHAPTER  IX 
SECONDARY  GLAUCOMA 

THE  study  of  secondary  glaucoma  is  of  importance  to 
the  general  practitioner  for  three  reasons. — 

1.  It  throws  a  valuable  light  on  the  aetiology  of  the 
primary  form  of  the  disease. 

2.  It  shows  the  need  for  early  and  careful  diagnosis. 

3.  It  emphasizes  the  fact  that  it  is  difficult  to  treat 
cases  of  this  kind,  for  the  obvious  reason  that  we  must 
not  only  strike  at  the  rise  in  intra -ocular  pressure,  but 
must  also,  and  in  the  first  instance,  direct  our  attention 
to  the  causative  condition,   which  is  not  seldom  very 
intractable. 

^Etiology. — The  causes  of  secondary  glaucoma  may  be 
divided  into  two  groups — viz.,  (a)  those  which  act  by 
bringing  about  a  closure  of  the  angle  of  the  anterior 
chamber,  and  thus  shutting  off  the  stream  of  fluid  from 
the  excretory  outlets  in  this  neighbourhood;  and  (6)  those 
which  owe  their  influence  to  a  change  in  the  constitution 
of  the  intra -ocular  fluid.  Such  change  may  be  either  due 
to  an  alteration  in  the  composition  of  the  fluid  (e.g.,  from 
the  presence  of  albuminous  matter  in  solution  therein), 
or  to  the  presence  of  epithelial  or  other  debris  therein. 
Both  these  changes  tend  to  block  the  excretory  channels 
mechanically,  and  so  to  impede  the  outflow  of  aqueous 
fluid  through  them. 

Secondary  glaucoma  may  be  brought  about  by  any  of 
the  following  conditions. — 

47 


48  GLAUCOMA 

Fistula  of  the  Cornea. — Whilst  the  fistula  is  open,  the 
^interior  chamber  lies  empty  for  a  longer  or  shorter 
period,  with  the  iris  base  in  contact  with  the  cornea; 
the  formation  of  exudate,  as  a  result  of  inflammatory 
action,  may  agglutinate  the  two  apposed  surfaces,  and 
so  cause  obliteration  of  the  angle  of  the  chamber.  When 
the  fistula  heals,  and  the  fluid  can  no  longer  escape 
through  it,  the  normal  channels  may  be  found  to  be 
occluded,  with  the  result  that  the  intra -ocular  pressure 
rises.  Later,  staphyloma  of  the  cornea  may  follow. 

Anterior  Synechia,  following  a  fistula  or  a  penetrating 
injury,  may  cause  such  displacement  forward  of  the  iris 
base  as  to  effect  an  obliteration  of  the  angle  of  the 
chamber.  Such  a  closure  is  usually  partial  in  the  early 
stage,  and  may  become  complete  later. 

Posterior  Ring  Synechia  leads  to  I' iris  bombe,  a  condition 
in  which  the  iris  is  pushed  forward  by  the  fluid  dammed 
up  behind  it.  The  result  is  an  obliteration  of  the  angle 
of  the  chamber,  which  adds  to  the  difficulty  already 
caused  by  the  want  of  a  free  circulation  through  the 
pupil. 

Anterior  Dislocation  of  the  Lens. — Here  the  iris  is  found 
wrapped  round  the  posterior  surface  of  the  lens,  and  also 
in  close  contact  with  the  cornea  peripherally,  thus  sealing 
the  angle  all  round. 

Lateral  Dislocation  of  the  Lens  acts  much  like  anterior 
synechia,  only  here  the  force  that  closes  the  angle  is  a 
push  from  behind  instead  of  a  pull  from  in  front.  It  also 
resembles  the  latter  condition  in  that  the  occlusion  is 
partial  in  the  first  instance  at  least. 

Injury  to  tJie  Lens. — As  a  result  of  accidental  trauma, 
the  capsule  of  a  lens  may  be  ruptured  or  pierced.  In 
either  case  the  lens  fibres  swell  up,  with  the  result  that 
the  lenticular  mass  increases  in  bulk,  and  so  comes  to 
press  upon  the  angle  of  the  chamber  and  occlude  it. 


SECONDARY  GLAUCOMA  49 

In  addition,  the  lens  masses  tend  to  pass  into  solution, 
and  so  to  change  the  constitution  of  the  aqueous,  render- 
ing it  less  able  to  pass  through  the  meshes  of  the  pectinate 
ligament.  We  have  thus  a  twofold  tendency  to  secondary 
glaucoma. 

Operations. — As  a  result  of  accidental  injury  during 
operations,  the  same  sequence  of  events,  as  has  above 
been  outlined,  may  take  place.  Moreover,  in  the  discis- 
sion  of  soft  cataracts  the  capsule  is  deliberately  cut  over 
a  limited  area,  with  a  view  of  letting  in  the  aqueous 
fluid;  the  swelling  produced  may  sometimes  outrun  our 
expectations  or  wishes,  and  then  secondary  glaucoma 
follows. 

After  Cataract  Extraction  a  dangerous  form  of  secondary 
glaucoma  is  sometimes  met  with.  It  may  be  due  to 
any  of  the  following  causes: — (1)  impaction  of  a  tag  of 
capsule  in  the  section ;  (2)  closure  of  the  pupil  by  exudate ; 
(3)  the  formation  of  a  membrane  behind  the  pupil,  which 
becomes  impermeable  to  fluid,  and  so  stops  the  passage 
of  the  aqueous  forwards;  (4)  the  presence  of  a  slow  irido- 
cyclitis,  with  all  that  this  connotes;  (5)  the  passage  of 
vitreous  fluid  forward  into  the  angle  of  the  chamber. 

Intra-ocular  Tumours. — These  set  up  a  low  form  of 
uveitis,  as  a  consequence  of  the  liberation  of  toxic  sub- 
stances by  the  growing  organism.  In  this  way  the  angle 
may  become  sealed. 

Cyclitis  acts  in  two  ways: — (1) by  sealing  up  the  angle 
of  the  chamber  with  exudate,  and  (2)  by  altering  the 
contents  of  the  aqueous.  The  chemical  constitution  of 
the  fluid  may  be  changed,  rendering  it  less  liable  for 
filtration ;  or  cellular  contents  may  be  added  to  it,  which 
tend  mechanically  to  block  up  the  meshes  of  the  pectinate 
ligament. 

Intra-ocular  Hcemorrhage  adds  suddenly  to  the  volume 
of  the  intra -ocular  contents;  it  also  makes  the  vitreous 

4 


50  GLAUCOMA 

more  albuminous,  and  so  promotes  an  osmotic  flow  into 
it  from  without. 

The  Diagnosis  ol  Secondary  Glaucoma. 

In  each  individual  case  the  signs  and  symptoms  of  the 
primary  disease  must  be  carefully  noted  and  their  signifi- 
cance weighed.  The  conditions  which  may  give  rise  to 
this  form  of  glaucoma  have  already  been  sufficiently 
indicated  in  the  previous  paragraphs. 

The  Treatment  of  Secondary  Glaucoma. 

In  all  cases  in  which  the  primary  disease  is  still  active, 
it  should  be  most  energetically  attacked,  regard  being 
had  not  merely  to  symptomatic  treatment,  but  above 
all  to  the  root-cause  of  the  condition.  To  take  one 
instance,  the  treatment  of  glaucoma  secondary  to  cyclitis 
is  incomplete  if  due  attention  be  not  paid  to  the  possi- 
bility that  pyorrhoea,  latent  gonorrhoaa,  syphilis,  or 
some  other  form  of  auto-intoxication,  may  be  at  the  root 
of  the  matter. 

When  the  iris  base  is  drawn  forward,  and  the  condition 
is  an  early  one,  iridectomy  is  indicated.  This  is  especially 
the  case  in  anterior  synechia. 

Pressure  by  a  dislocated  lens  or  by  masses  of  lens  matter, 
following  any  form  of  trauma,  demands  the  free  evacua- 
tion of  the  offending  material. 

Glaucoma  secondary  to  the  swelling  of  a  maturing 
cataract  is  best  met  by  a  prompt  iridectomy.  That  due 
to  the  formation  of  an  impervious  after-cataract  may 
sometimes  be  relieved  by  free  discission  of  the  obstructing 
membrane.  Glaucoma  folio  whig  cataract  extraction,  in 
the  absence  of  any  such  membrane,  often  yields  promptly 
and  permanently  to  trephining.  Where,  however,  it  is 
due  to  the  vitreous  passing  freely  through  the  pupil  into 


SECONDARY  GLAUCOMA  51 

the  anterior  chamber,  and  there  proving  too  viscid  to 
allow  of  the  natural  escape  of  the  fluid,  it  is  doubtful  if 
anything  can  be  done. 

The  presence  of  an  intra -ocular  tumour  indicates  the 
need  for  an  excision  of  the  eyeball. 

In  haemorrhagic  cases  medicinal  and  general  treatment 
are  probably  the  safest,  though  under  desperate  circum- 
stances it  may  be  permissible  to  trephine. 

The  treatment  of  iritis  and  cyclitis  is  on  ordinary 
lines;  paracentesis,  however,  should  always  be  kept  in 
reserve. 

There  are  few  more  difficult  things  to  decide  than  the 
best  method  of  immediate  treatment  of  a  case  of  acute 
or  subacute  congestive  glaucoma.  The  use  of  eserine, 
which  will  open  the  angle,  will  at  the  same  time  increase 
the  congestion  present.  Atropine  will  reduce  the  con- 
gestion, but  will  increase  the  difficulty  opposed  to  the 
outflow  of  the  intra -ocular  fluid.  Operation  in  any  form 
is  dangerous,  though  it  may  have  to  be  undertaken. 
There  are  cases  in  which  the  bold  use  of  atropine  or  of 
eserine,  selected  according  to  the  exigencies  of  the  in- 
dividual case,  may  prove  invaluable,  and  there  are  times 
when  operation  must  be  undertaken  and  the  fate  of  the 
eye  risked  on  the  result  of  a  single  throw.  The  practi- 
tioner will  be  well  advised  if,  under  such  circumstances, 
he  places  the  responsibility  on  an  expert,  if  possible. 
In  the  meantime  the  patient  should  be  kept  in  bed,  the 
forehead  and  temple  should  be  freely  leeched,  and  vigor- 
ous fomentations  applied.  Free  purgation  should  be 
established,  but  not  pushed  after  the  first  twenty-four 
hours.  Morphia  should  be  used,  if  not  otherwise  contra - 
indicated,  to  relieve  pain  and  to  obtain  sleep,  and  the 
patient  should  be  kept  quiet,  in  a  shaded  light.  Needless 
to  say,  all  the  individual  indications  previously  dealt 
with  should  be  carefully  attended  to.  The  surgeon  must 


52  GLAUCOMA 

always  remember  that  the  aim  of  his  treatment  is  not 
merely  to  bring  the  patient  through  a  painful  period  into 
a  condition  of  physical  quiescence,  but  also,  and  above 
everything  else,  to  save  as  much  vision  as  possible.  If  he 
fails  in  this  last  respect,  he  has  practically  failed 
altogether. 


CONGENITAL  GLAUCOMA 

BY  this  we  understand  glaucoma  which  is  congenital  in 
origin.  A  large  percentage  of  such  cases  are  also  con- 
genital in  their  manifestation  of  the  condition,  though 
the  earliest  signs  of  many  such  are  undoubtedly  over- 
looked both  by  medical  men  and  by  parents.  At  the 
other  pole  of  life — say  from  the  age  of  forty  onward — 
are  found  the  cases  of  senile  glaucoma.  Intermediate 
between  the  two,  too  late  to  be  classed  as  congenital, 
too  early  for  the  senile  group,  are  a  number  which, 
for  convenience'  sake,  we  call  "juvenile."  Speaking 
generally,  congenital  glaucoma  is  due  to  defects  in  the 
development  of  the  excretory  passages,  whilst  senile 
glaucoma  is  to  be  attributed  to  degenerative  and  other 
changes  which  accompany  the  advance  of  age.  It  is 
probable  that  both  elements  play  a  part  in  the  juvenile 
cases,  and  the  preponderance  of  one  or  the  other  in- 
fluence determines  whether  the  case  is  an  early  or  a  late 
juvenile  one,  and  so  whether  it  is  in  danger  of  being 
confused  with  those  of  the  congenital  or  senile  classes. 
The  terms  "  buphthalmos  "  and  "  hydrophthalmos  "  are 
synonyms  of  congenital  glaucoma . 

Signs  and  Symptoms  o£  Buphthalmos. 

The  condition  is  usually  noticed  at  birth  or  before  the 
third  year,  and  is  bilateral  in  the  great  majority  of  cases. 
Boys  are  more  frequently  affected  than  girls. 

53 


54  GLAUCOMA 

The  eye  enlarges  slowly  but  steadily,  and  may  attain 
enormous  proportions.  The  whole  globe  is  uniformly 
distended.  Proptosis,  lagophthalmos,  and  limitation  of 
ocular  movement  follow.  The  great  enlargement  of  the 
cornea  is  a  striking  and  obvious  feature.  That  membrane 
may  retain  its  lustre,  or  it  may  become  scarred  in  various 
ways. 

The  anterior  chamber  is  greatly  deepened.  The  sclent, 
is  evenly  distended,  and  the  uveal  pigment  shows  through 
the  thin  coat,  making  the  white  of  the  eye  appear  of  a 
bluish  colour.  The  iris  is  tremulous;  the  pupil  is  round, 
sluggish,  and  slightly  dilated.  The  lens  is  normal  in 
size  or  smaller  than  natural,  and  is  tremulous  owing 
to  the  overstretching  of  its  suspensory  ligament.  The 
vitreous  may  be  clear  or  more  or  less  cloudy.  The 
choroid  is  overstretched  and  atrophic.  The  retina  is 
overstretched,  and  detachment  may  take  place.  The 
optic  disc  is  cupped.  The  tension  of  the  eye  is  raised, 
sometimes  very  markedly  so ;  owing  to  the  alteration  in 
the  curve  of  the  cornea,  the  ordinary  tonometer  cannot 
be  used,  and  we  must  rely  on  a  finger  examination.  The 
visual  acuity  is  often  much  impaired  owing  to  changes  in 
the  media  and  in  the  optic  nerve  and  retina.  A  moderate 
myopia  is  usually  present,  often  associated  with  astig- 
matism, but  its  correction  by  glasses  is  difficult.  .Nystag- 
mus is  common.  The  children  are  usually  backward 
and  diffident,  and  their  general  health  is  often  below  par. 

Clinical  Course  and  Complications. 

The  great  majority  of  cases  go  steadily  downhill  to 
loss  of  vision,  either  through  retinal  degeneration  or 
opacification  of  the  media,  or  both.  A  few  cases  stop 
spontaneously;  yet  others,  and  these  fewer  still,  retain 
throughout  comparatively  normal  functions.  It  has  been 


CONGENITAL  AND  JUVENILE  GLAUCOMA   55 

suggested  that  the  last  class  represent  a  gigantism  of  the 
eye,  for  which  the  name  "  megalocornea "  has  been 
proposed.  This  is  a  disputed  question.  The  buphthalmic 
eye  is  very  liable  to  injury.  In  a  few  cases  buphthalmos 
is  associated  with  an  obscure  condition  termed  "  neuro- 
fibromatosis." 

Differential  Diagnosis  of  Buphthalmos. 

Buphthalmos  must  be  distinguished  from  megalo- 
cornea, juvenile  glaucoma,  keratoconus,  keratectasia, 
staphyloma,  and  exophthalmos.  The  first  two  condi- 
tions have  already  been  dealt  with.  In  the  remaining 
four  the  diameter  of  the  corneal  base  is  not  increased, 
whilst  in  congenital  glaucoma  it  is  above  the  normal  and 
continues  to  enlarge. 

The  Pathological  Anatomy  and  2Etiology  of  Buphthalmos. 

The  leading  points  are  as  follows. — (1)  The  cornea  is 
very  liable  to  damage,  especially  on  its  posterior  surface, 
due  to  overstretching  and  consequent  tearing  of  the 
membrane  of  Descemet.  This  gives  rise  to  characteristic 
scars  at  the  back  of  the  cornea.  (2)  The  anterior  chamber 
is  very  deep,  and  its  angle  appears  to  be  widely  open. 
This  appearance  is  often  deceptive,  as  has  been  proved 
by  anatomical  examination,  for  the  angle  is  frequently 
found  to  be  closed  by  bands  in  this  neighbourhood. 
These  represent  a  foetal  condition  of  development.  The 
canal  of  Schlemm  is  often  absent  or  insufficiently  de- 
veloped. It  is  this  deficiency  of  the  normal  passages  for 
the  excretion  of  intra -ocular  fluid  which  is  the  paramount 
factor  in  the  aetiology  of  buphthalmos.  The  influence  of 
heredity  is  well  marked,  and  is  probably  a  question  of  the 
inheritance  of  the  above-mentioned  defective  develop- 


50  GLAUCOMA 

ment.  The  next  point  of  importance  is  the  distensibility 
of  the  young  eye,  which  accounts  for  and  permits  the 
great  enlargement  characteristic  of  the  disease,  and  which 
is  not  present  in  older  globes. 

Buphthalmos  not  seldom  follows  an  injury  or  inflam- 
mation of  the  eye.  In  most  of  these  cases  the  condi- 
tion is  probably  quite  distinct  from  that  of  congenital 
glaucoma ;  they  really  are  instances  of  secondary  glaucoma 
occurring  in  young  and  therefore  distensible  eyes. 


JUVENILE  GLAUCOMA 

This  group  comprises  a  great  variety  of  forms,  some 
of  which  are  really  congenital  in  origin  (though  their 
onset  may  be  delayed  or  may  at  first  escape  observation), 
whilst  others  closely  resemble  the  different  forms  of 
senile  glaucoma.  Every  variety  of  senile  glaucoma  may 
be  imitated,  from  the  simple  to  the  most  acute.  A  very 
interesting  feature  is  the  common  association  of  juvenile 
glaucoma  with  myopia.  Another  is  the  tendency  for 
the  early  stage  of  the  disease  to  be  prolonged  owing  to 
the  fact  that  the  yielding  of  the  young  globes  staves  off, 
for  a  time  at  least,  the  worst  consequences  of  the  rise  in 
intra-ocular  pressure. 

It  cannot  be  too  strongly  insisted  on,  that  there  is  no 
essential  difference  between  the  various  forms  of  glau- 
coma. The  best  evidence  of  this  is  found  in  the  following 
facts.  When  glaucoma  affects  several  successive  genera- 
tions, it  tends  to  be  of  the  senile  type  in  the  first  genera- 
tion, and  more  and  more  of  the  juvenile  type  in  the  later 
ones.  Again,  in  a  single  generation  of  one  family  in- 
stances may  occur  of  juvenile  glaucoma  in  some  members, 
and  of  buphthalmos  in  others.  Lastly,  a  single  individual 
may  have  buphthalmos  in  one  eye,  and  juvenile  glaucoma 
in  the  other. 


The  Treatment  o£  Congenital  and  Juvenile  Glaucoma. 

The  treatment  of  these  conditions  by  medicine  has 
been  very  unsatisfactory.  Inasmuch  as  some  few  of 
them  either  never  lead  to  serious  symptoms,  or  else  tend 
to  come  to  a  full-stop  by  themselves,  it  is  well  to  watch 
each  patient  closely,  and  only  to  decide  on  active  inter- 
ference when  the  case  is  steadily  going  downhill.  The 
reliance  to  be  placed  on  meiotic  and  similar  treatment 
is  "  expectant  "  only  of  disaster.  If  operation  is  decided 
on,  it  should  be  undertaken  at  the  earliest  possible 
moment.  Iridectomy  has  been  practically  abandoned 
as  unduly  dangerous  in  these  conditions. 

Many  forms  of  operation  have  been  tried,  with  varying 
success.  Sclerectomy  has  proved  more  satisfactory  than 
sclerotomy  or  anything  else,  and  trephining  appears  to 
have  yielded  the  best  results  of  any  procedure.  It 
would,  none  the  less,  be  idle  to  conceal  the  fact  that,  do 
what  we  may,  the  prognosis  of  a  case  of  buphthalmos  is 
not  a  very  happy  one.  On  the  other  hand,  the  dismal 
certainties  that  attend  inaction  make  it  imperative  that 
we  should  not  hesitate  to  shoulder  our  responsibilities 
towards  the  patients  and  their  relatives.  The  author's 
personal  experience  has  shown  him  that  a  certain  number 
of  cases  will  yield  results  which,  if  not  brilliant,  are  at 
least  highly  gratifying,  inasmuch  as  they  enable  a  child 
to  see  and  to  play  a  useful  part  in  life.  It  is  certainly 
worth  operating  on  ten  cases  to  get  five  such  results, 
and  that  is,  we  think,  somewhere  near  the  probabilities  of 
the  matter. 


INDEX 


A. 

ABSOLUTE  glaucoma,  23 

Acute  glaucoma,  2,  45 

Age,  a  cause  of  glaucoma,  17 

Alterations  in   anatomical   con- 
ditions of  eye,  17 

Anaesthesia  or  cornea,  26 

Angle  of  chamber,  closure  of,  4, 

14,  47 
obliteration  of,  5,  48 

Anterior    chamber,     shallowing 
of,  15,  26 

Anterior  synechia,  48 

Arguments    against    operating 
for  glaucoma,  45 

Auto-intoxication,  17 

B. 

Bilateral  disease,  glaucoma  a,  23 
Bilious  headache,  34 
Blind  painful  eyeball,  23 
Blood-pressure,  intra-ocular,  10, 
11,  12 

systemic,  10 
Buphthalmos,  53 

aetiology  of,  55 

course     and     complications 
of,  64 

differential  diagnosis  of,  55 

pathological  anatomy  of,  55 

signs  and  symptoms  of,  53 

treatment  of,  57 

C. 

Cataract    extraction,  glaucoma 

following,  49 
forms  of,  27 
Causes  of  glaucoma,  17 
Chemosis,  22 

Choroidal  circulation,  6,  30 
Chronic  glaucoma,  2 


Ciliary  body,  3,  4,  5,  26 

fluid  secreted  by,  5 
glands  of,  5 

Ciliary  nerves,  6 

Ciliary  processes,  15 

Ciliary  vessels,  6 

Coloboma  of  disc,  30 

Congenital  glaucoma,  53 

Congestive  glaucoma,  2,  7,   15, 
19,  20,  21 

Conjunctiva,  3,  25 

Conjunctivitis,  34 

Cornea,  25 

size  of,  at  birth,  15 
splitting  the,  3,  43 

Cupping  of  disc,  glaucomatous, 

7,  27 
non-glaucomatous,  30 

Cyclitis,  49 

Cyclo-dialysis,  5,  44 

D. 

Degenerative  changes  in  eye,  17 
Device  to  explain  cupping,  28 
Diagnosis,  difficulties  in,  19 
Differential  diagnosis,  33 
Dimensions      of      glaucomatous 

eyes,  15 

Distensibility  of  ocular  tunic,  8 
Distension  of  ocular  tunic,  10 

E. 

Early  operation,  37,  39 
Elasticity  of  ocular  tunic,  8,  10 
Elliot's  operation,  42 


F. 


cause    of 


Febrile    diseases,     a 

glaucoma,  18 
Fergus  operation,  41 
Fibrosis  of  pectinate  ligament, 

14,  17 


58 


INDEX 


Filtering  cicatrix,  39 
Filtration  angle,  closure  of,  14, 

15 

Fistula  of  cornea,  48 
Flashes  of  light,  21 

G- 

General  treatment  of  glaucoma, 

35 
Glaucoma      cup,      overhanging 

edges  of,  7 
Green  reflex,  22,  23,  27 

H- 

Haemorrhage,  intra-ocular,  49 
Hsemorrhagic  glaucoma,  51 
Herbert's  operation,  40 
Heredity,  influence  of,  18,  55 
Holth's  operation,  41 
Hydrophthalmos,  53 
Hydrophyllic  theory,  14 

I. 

Inflammatory  glaucoma,  2 
Injuries,  a  cause  of  glaucoma, 

18 
Intra-ocular   fluid,   direction   of 

flow,  5 

drainage  of,  9 
source  of,  9 
vicarious     channels     of 

excretion  of,  11,  12 
volume  of,  10,  11,  12 
Intra-ocular  pressure,  1,  8,  10, 

11,  12 

conditions  regulating,  8 
Intra-ocular  tumours,  49 
Iridectomy,  38,  57 
Iris  bombe,  48 

crypts  of,  5,  9 
dilatation    of   pupil,    4, 

22,  26 
Iritis,  34 

J 

Juvenile  glaucoma,  53^ 
treatment  of,  57 

L. 

Lagrange's  operation,  40 
Late  infection,  46 
Lens,  26 

advance  of,  4,  15,  17 

dislocation  of,  48 

growth  of,  4,  15.  16,  17 

injury  to,  48 


M. 

Manometer  readings,  8 
Massage,  37 
Meiotics,  35,  36,  37 
Memory  sight,  23 
Mistiness  of  vision,  21,  25 
Mydriasis,  dangerous,  18,  35 

N. 

Nerve  shock  and  strain,  18 
Non-congestive  glaucoma,  2,  19, 
20 

0. 

Operative  treatment,  38 
Optic  nerve,  27 

atrophy  of,  13 

entrance,  7 
Osmotic  action  in  iris  veins,  5,  9" 

P. 

Pain,  22,  31 

Panophthalmitis,  23 

Paracentesis,  51 

Pathological  anatomy,  13 

Pectinate  ligament,  3,  5,  9 
fibrosis  of,  17 
perforating  vessels,  6 

Photopsiae,  31 

Post-operative  glaucoma,  49 

Primary  glaucoma,  1 

Prodromata,  19,  21 

Pulsation  of  retinal  vessels,  30 

Pump  action  of  ciliary  muscle, 
4,  9,  14 

Pyrexia,  31 

R. 

Rainbow  rings,  21,  25,  31 
Refraction,  errors  in,  18 
Retina,  27,  30 
Retinal  circulation,  6,  30 
Ring  synechia,  48 

S. 

Schlemm's  canal,  3,  5,  9,  14 
Sclera,  25 

cessation  of  growth  of,  15 
Sclera  spur,  3,  9 
Sclero-corneal  trephining,  42 
Secondary  glaucoma,  1,  47 
diagnosis  of,  50 
treatment  of,  50 
Selection  of  operation  for  glau- 
coma, 44 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 

This  book  is  DUE  on  the  last  date  stamped  below. 


Form  L9-Series  4939 


H.  K.  LEWIS  &  00    LTD.,  I3f,  OOTTUR  STJ'.E' 


ooo  too      u 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 

This  book  is  DUE  on  the  last  date  stamped  below. 


A     000  388  435     o 


